Including Conflict of Interest, Confidentiality, Work-For-Hire, and Hold Harmless Obiligations

Please read AHIMA’s Participation Agreement and Conflict of Interest Policy and Procedure before electronically submitting the participation agreement. The Participation Agreement and AHIMA policy and procedure include definitions, purpose, interested persons, confidentiality, work-for-hire, and held harmless provisions. If you have any questions, please email Volunteer Services.

All volunteers are required to complete the participation agreement.  Please complete the agreement as soon as possible.  It is very important to understand that you will be responsible for evaluating situations in which you may find yourself representing multiple interests. The main objective of this form is to identify your role and dualities and/or any conflicts you may have.

Any question with an asterisk is a required field. 

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* 1. Please select the group you volunteer for:

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* 2. What is your AHIMA Member ID #?

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* 3. What is your full name?

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* 4. Do you or your family members provide to, or have any financial interests in third parties that provide goods or services to AHIMA or its Related Organization?

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* 5. Do you serve as an officer on a governing body, as a committee chair or committee member of any entity other than AHIMA or a Related Organization, whether for-profit or non-profit?

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* 6. Do you expect to receive Compensation from AHIMA or a Related Organization, other than reimbursement of reasonable expenses?

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* 7. Do you have family members who expect to receive any form of payment or other renumeration from AHIMA or a Related Organization?

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* 8. Outside of the capacity as a leader, volunteer or employee of AHIMA or a Related Organization, do you have a Business Relationship with any directors, officers, commissioners, volunteer members, committee or task force members, or employees of AHIMA or a Related Organization?

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* 9. Outside of the capacity as a leader, volunteer or employee of AHIMA or a Related Organization, do you have a Family Relationship with any directors, officers, commissioners, volunteer members, committee or task force members, or employees of AHIMA or a Related Organization?

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* 10. Please list any additional circumstances which constitute or may constitute a Conflict of Interest.

Conflict of Interest Terms and Conditions
  • I have read the AHIMA Participation Agreement, including conflict-of-interest, confidentiality, work-for-hire, and hold harmless obligations, and have made full and complete disclosures related to any conflict-of-interest I may have.
  • I understand that I am required to notify Volunteer Services in the event of any material change to the answers I have provided in this statement.
  • I agree to provide any information requested by, and comply with all directives of, the AHIMA Board Governance committee with respect to any conflict-of-interest.
  • I will not accept any service, discount, concession, fee for advice or service from any person or organization with an interest in an issue, matter or transaction in which AHIMA also has an economic or programmatic interest under circumstances that would suggest an obligation on my part to exert any influence on AHIMA or its affiliates to enter into transaction or adopt, alter or abolish any policy or position.
  • I will contact the AHIMA Board Governance Committee if I observe or become aware of any violation of the AHIMA Participation Agreement and confidentiality, conflict-of-interest obligations.
AHIMA requires that you certify your conflict disclosure form and confirm your agreement to the Participation Agreement by submitting an electronic signature. By typing your name and AHIMA ID # above and entering today's date below you are providing your electronic signature and that you acknowledge and agree to the obligations of conflict-of-interest, confidentiality, work-for-hire, and hold harmless obligations of AHIMA's Participation Agreement. Click "SUBMIT" below to confirm your signature.

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* 11. Enter your signature and today's date for confirmation of this agreement

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