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EACH YEAR THE SPINE INTERVENTION SOCIETY (SIS) REQUIRES ALL VOLUNTEERS (INCLUDING OFFICERS, COMMITTEE MEMBERS, TASK FORCE MEMBERS, INSTRUCTORS, SPEAKERS, RESEARCH ACTIVITY APPLICANTS, AND THOSE WHO WISH TO BE CONSIDERED FOR THOSE ROLES) TO DISCLOSE POTENTIAL CONFLICTS OF INTEREST THAT MAY INFLUENCE THEIR INVOLVEMENT.

Volunteers must disclose all personal financial interests, affiliations, and relationships, including those of family members (spouses, domestic partners, parents, children, and siblings) that may be perceived as potentially influencing either their actions 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 volunteer, the volunteer’s family, employer, or other persons with whom the Discloser maintains a relationship. The potential for a conflict of interest can exist whether or not one believes that a relationship may affect their judgment.

This disclosure, assignment, and affirmation is intended to supplement, but not replace, any legal requirements applicable to non-profit and charitable corporations.

All volunteers must alert the Society to any changes that have bearing on this disclosure, assignment, and affirmation by submitting a revised form.

If applicable, the appropriate division, committee, program chair/moderator, or board chair will review these materials prior to participation in SIS activities. For more information, please see the Society’s Disclosure Policy.

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* 3. Please indicate your current involvement with SIS:
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* 4. Please indicate your desired involvement with SIS, or purpose for submitting this disclosure:
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