APSNA Declaration of Interest Form

Name*

First NameMiddle NameLast Name

Credentials (Abbreviations Only)

Current Position*

Professional Title*

Employer*

Department

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Email*

example@example.com

Conflict of Interest Policy

The APSNA mission is that APSNA will be the voice that shapes pediatric surgical nursing through advocacy, collaboration, mentorship and leadership. Based on a foundation of research, education and innovation, APSNA will transform care delivery for pediatric surgical patients. This mission is the primary interest that will be prioritized in all APSNA activities. A conflict of interest thus compromises an individual’s accountability to APSNAs Mission and to those that APSNA aims to serve and risks erosion of the trust placed in APSNA to fulfill this mission.

APSNA requires individuals subject to the Conflict of Interest Policy to read this policy, confirm receipt and agree to compliance, and to disclose all relevant interests, including, but not limited to financial relationships with entities that could be affected financially by the activities of APSNA, such as Pharmaceutical, Biotech, Food & Nutrition, and Medical Devices and Equipment companies, or foundations, advocacy groups, or other organizations supported by entities that may have a financial stake in the outcome. Public funding sources, such as government agencies or academic institutions need not be disclosed. Time period for disclosure is within 5 years from when this form is completed.

I have read the Conflict of Interest Policy and I agree to comply in all respects with this policy.*

Yes, I agree.

Section 1. Individuals subject to this policy need to disclose all relationships whereby they or immediate family member members have a financial interest/arrangement or affiliation with an entity that could potentially benefit financially from APSNA’s activities. An immediate family member is defined as a partner with whom participant has lived for ≥1 y in the same home, dependent or any other related person (by blood or marriage) with whom participant has lived for ≥1 y in the same home.

Name / Position*

Employment*

Relevant Committee / Group*

Role (member, chair, committee, other as above)*

Financial Interests
Note: Disclose support ONLY from entities that could be affected financially by APSNA’s activities, such as Pharmaceutical, Biotech, Food and Nutrition, and Medical Devices and Equipment companies, or foundations, advocacy groups, or other organizations supported by entities that may have a financial stake in the outcome. Public funding sources, such as government agencies or academic institutions need not be disclosed. Time period for disclosure is within 5 years from when this form is completed.

If activity was linked to a specific product, please name the product: i.e., “fees for speaking about product X or consulting regarding product X.

Directions:

Every field is mandatory, regardless of whether or not you have a disclosure. Please fill in every cell. If you have no disclosures for a given cell, please type “NA”.

Employment*