Please initial below that you have read and understood that, in accordance with the Ethics Policy, if you have a personal or business relationship with the complainant or the respondent you must declare a conflict of interest:

Yes, I have read this and will adhere to the policy:   Inital*    

Please initial below that you have read and understood that, in accordance with the Ethics Policy, "Attempts by any individual to interfere with, delay or manipulate the work of the Complaint Review Committee may be subject to sanctions by the Complaint Review Committee (including but not limited to probation, suspension, revocation of membership, mandatory professional education, or any other such redress to the ethical violation as the committee may find appropriate in the circumstances).":

Yes, I have read this and will adhere to the policy:   Inital*    

Please initial below that, in accordance with the Ethics Policy, you agree to review and sign the Code of Confidentiality and review the Volunteer Boundary Document, both of which have been provided to you:

Yes, I have read this and will adhere to the policy:   Inital*    

Please initial below that, in accordance with the Ethics Policy, you agree to permanently delete all emails, files, and documents following the conclusion of a complaint:

Yes, I have read this and will adhere to the policy:   Inital*    

I,   First Name*   Last Name*  solemnly swear that the above information is true and answered to the best of my knowledge and ability.

This is to certify that as a POC Ethics Complaint Review Committee member I,First Name*   Last Name*, understand that any information (written, verbal, or any other form) obtained during the performance of my duties as an Ethics Complaint Review Committee member must remain confidential. This includes all information about a complaint itself as well as the identities of those participating in a complaint procedure.

I understand that any unauthorized release or carelessness in the handling of this information is considered a breach of the duty to maintain confidentiality. Devices containing confidential information must be kept private and/or password protected.

I further understand that any breach of the duty to maintain confidentiality may be grounds for immediate removal from the Ethics Complaint Review Committee and the initiation of an ethics violation complaint against me.