Exit this survey

All SIS volunteers, potential volunteers, speakers, and research activity applicants are required to submit a disclosure. Potential for conflict of interest can exist whether or not the Discloser believes that the relationship affects his or her judgment.

This disclosure form is intended to supplement, but not replace, any applicable state laws governing conflicts of interest applicable to non-profit and charitable corporations.

Disclosers must disclose all personal financial interests, affiliations, and relationships, including those of family members (spouse, domestic partner, parent, child, and sibling) that may be perceived as potentially influencing either the Discloser or society-supported activities. Conflicts of interest pertain to, without limitation, subject matter that has a reasonable potential to result in financial, professional, or other personal gain or loss for the Discloser, the Discloser’s family, employer, or other persons with whom the Discloser maintains a relationship.

If any changes occur to the disclosed information after the form is submitted, a new/updated form must be submitted to SIS immediately.

If applicable, the appropriate division, committee, program chair/moderator, or board chair will review your disclosures prior to participation.

For more information, please see the Society's Disclosure Policy.

Question Title

* 1. Please provide your name details:

Question Title

* 2. Please tell us how you would like your name listed on the SIS website and any printed materials. (Example: Patty/Pat Smith, MD vs. Patricia/Patrick Smith, MD)

Question Title

* 3. Mobile Phone Number:

Question Title

* 4. Please indicate your current involvement with SIS:
                      Select all that apply:

Question Title

* 5. Please indicate your desired involvement with SIS, or purpose for submitting this disclosure:
Select all that apply:

( Privacy & Cookie Notice

T