Section 1 - Instructions and Identity

Please read and acknowledge receipt of this information.

Disclosure of interests (DOI) is necessary to ensure that ASAM clinical practice guidelines (CPG) and The ASAM Criteria provide a balanced, independent, objective and scientifically rigorous product by understanding other factors that could potentially influence the work and decision making of the CPG committee. DOI does not automatically imply conflict of interest (COI). COI is determined based on the content of the DOI and is a determination made by an independent committee, not by the person submitting the DOI.

This survey will collect disclosures of interest in the following categories in the last 24 months. Please note that this DOI form is much more inclusive than other DOI form you may fill out for CME Programs (see here for an overview of disclosure categories):

· Employment
· Research and Consulting Financial Support Related to Addiction Medicine or Behavioral Health
· Investments and Proprietary Interests Related to Addiction Medicine or Behavioral Health
· Membership on Healthcare-Related Boards, Panels, Organizations, or Societies
· Formal Advocacy or Lobbying Activities Related to Addiction Medicine or Behavioral Health

All DOI for CPGs will be reviewed by ASAM’s Methodology Oversight Subcommittee and Ethics Committee. If a DOI is deemed to be a COI, a tier will be assigned to the COI and a mitigation plan will be implemented for any moderate- or high-level COI. This process is necessary to prevent actual or perceived bias during CPG development and to ensure credibility and public trust in ASAM CPGs.

For more information, please refer to the ASAM Methodology for Clinical Practice Guidelines.

By completing this DOI form, you are acknowledging you have read and understand the information presented.

Instructions: Please answer each question to the best of your ability, both for yourself and your partner/spouse if applicable, erring on the side of full disclosure of all relationships and activities in the past 24 months. This survey will take about 5-20 minutes to complete depending on how many relationships you have to disclose. You may be asked to further describe your DOI if more information is required to determine whether a COI exists. We recommend that you include all DOI to prevent delays in this process. Your CV will also be requested and follow-up questions may be asked relating to DOI information included in your CV that is not included in this form.

For questions regarding DOI related to CPG, please email quality@asam.org.

For questions regarding DOI related to the ASAM Criteria, please email asamcriteria@asam.org.

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* Name

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* Please attach a copy of your CV.

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* Do you currently or have you had a partner/spouse within the past 24 months?

 
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