Thank you for your interest in serving on a Spine Intervention Society (SIS) Division or Committee! As a volunteer organization, we depend on the time, effort, and expertise of our dedicated members to fulfill our mission and vision.

You are asked to complete this Disclosure survey in accordance with the Spine Intervention Society Disclosure Policy. The purpose of the disclosure policy is to protect the interest of the Society (“the Corporation”) when it is contemplating entering into a transaction or arrangement that might benefit the private interest of a director, officer, division or committee member, speaker, author on Society publications, or manager of the Corporation. This policy is intended to supplement but not replace any applicable state laws governing conflicts of interest applicable to non-profit and charitable corporations.

The potential for conflict of interest can exist whether or not the Discloser believes that the relationship affects his or her judgment.

This disclosure policy applies to all participants in any and all Society activities, including those who serve in committee and leadership positions within the society, including but not limited to, directors, officers, division members, committee members, speakers, faculty, instructors, authors on Society publications, and managers of the Corporation.

Disclosers must disclose any and all personal financial interests, affiliations, personal relationships (including family members such as spouse, domestic partner, parent, child, sibling), and other relationships perceived as potentially influencing the board, division, committee, or task force activities. Conflicts of interest include, 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 Discloser maintains a relationship. The Discloser’s financial disclosure is based on a time period of one year prior to the survey's submission, the current year, and the foreseeable future.

For more information, please see the Spine Intervention Society Disclosure Policy, which is available on our Web site,

Please mark "No Relationship" where applicable, otherwise all positive answers require a company name and relationship with entity.

The appropriate Division chair will review your disclosure before any division or committee work. Any conflict must have resolution prior to participation. If you become involved with any entity that may present a conflict within the year, you must update your disclosure.

Any refusal to disclose relevant financial relationships may result in the member's disqualification from consideration as a member of a Spine Intervention Society division or committee.

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* 1. Please provide your name:

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* 2. Do you have or have you had any financial interest in the health care industry or other relevant entities in the past 12 months?
Financial interest means ANY financial interest which contributes to you or your family members’ income. This includes:

  No Relationship Yes
Stock ownership or investment interest (including options, warrants)
LLC ownership of medical company
Any position as proprietor, director, managing partner, or key employee
Service as a director, consultant, expert witness, speaker, author
Advisory committees or review panels
Private investments, (venture capital, startup)
Intellectual property rights
Grant & research support
Royalties and travel arrangements
Other financial or material support in conflict with participation

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* 3. Please identify any business interests, other than investments, in relation to the health care industry or other relevant entities, held by you individually or by family members in the past 12 months. Please indicate the company and relationship.

  No Relationship Yes
Are you a board member, officer, partner, participate in management (directly or indirectly), or otherwise hold a position of influence in any firm or organization from which this Corporation secures goods or services (including the services of buying or selling stocks, bonds, or other securities, or of a banking relationship)?
Are you involved directly or indirectly in any activities or transactions which might affect the Corporation and its affiliates in the purchase or sale of real estate and other tangible or intangible rights or interests?
In the past year, did you receive, or become entitled to receive, directly or indirectly, any personal benefits from the Corporation or as a result of your relationship with the Corporation, that in the aggregate could be valued in excess of $1,000, that were not or will not be compensation directly related to your duties to the Corporation?
Are you aware of any other events, transactions, arrangements, or other situations that have occurred or may occur in the future that you believe should be examined by the Corporation’s board or the executive committee in accordance with the terms and intent of the Corporation’s Conflict of Interest Policy?

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* 4. INVESTMENTS: Indicate if you and your family members have any investments of a substantial nature in any firm or organization from which the "Corporation" secures goods or services; or, in any firm or organization which is a competitor of the institution or institutions comprising the "Corporation" and its affiliates.

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* 5. OUTSIDE ACTIVITIES: Please identify any outside activities in the past 12 months for yourself and your family members that could be a conflict of interest towards the "Corporation" as described as follows:

  No Relationship Yes
Are you a director or trustee of any firm or organization which does business with the Corporation; or, do you offer any managerial or consultative services to any firm or organization which does business with the Corporation?
Are you presently a director or trustee of any other health care institution?
Do you offer any managerial or consultative services to any other health care institution or organization other than those which comprise the Corporation and its affiliates?
Are you presently a director or trustee and/or do you offer any managerial or consultative services to any competitors of the Corporation or its affiliates?

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* 6. ACCEPTANCE OF GIFTS OR SERVICES: Please list gifts, favors, services, and other things of value retained from the Corporation vendors, which are in excess of a total annual value of $50.00 per gift/occurrence (or entertainment and social event courtesies which exceed a total annual value of $100.00) for you and your family members.

  None Yes

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* 7. OTHER: Are there any other activities in which you and your family members are engaged that could possibly be regarded as constituting a conflict of interest:

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* 8. I HEREBY AGREE to report to the Chair of the Board, President, CEO, or Division Chair any situation which may develop in the future.

By entering my name, date, and email address, I am verifying that I have read this disclosure document and have disclosed information regarding relevant financial relationships with commercial interests or potential conflicts of interest in the past 12 months.

Thank you for taking the time to fill out this important disclosure survey. Any situation that may be regarded as a conflict of interest will be reviewed by the Society's Board of Directors or Division Chair.

Please contact the SIS office at 630-203-2252 for additional information and questions.

The Spine Intervention Society's Disclosure Policy is available on our website: