SIS Financial Disclosure Survey - Call for Volunteers

Thank you for your interest in a Spine Intervention Society (SIS) grant opportunity or volunteer position.

All SIS volunteers, potential volunteers, and grant 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 the grantee or research implementation or board, division, committee, or task force 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.

The appropriate division, committee, or board chair will review your disclosures as part of grant application evaluation or prior to group participation.

For more information, please see the Society's Disclosure Policy on the SIS website http://www.spineintervention.org/?page=disclosure_policy

Question Title

* 1. Please provide your name details:

First Name:

Last Name:

Credentials:

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. Please indicate your involvement, or desired involvement, with SIS:
Select all that apply:

Grant Applicant

Board of Directors

Instructor

Education Division (ED)

ED: CME Committee

ED: Instructor Development Committee

ED: International Education Committee

Fundraising Committee

Health Policy Division (HPD)

Membership Committee

Research Division

Standards Division (SD)

SD: AUC Committee

SD: Evidence Analysis Committee

SD: Patient Safety Committee

Survey the SIS Membership Applicant

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. Please indicate your involvement, or desired involvement, with SIS: Select all that apply:

* 3. Please indicate your involvement, or desired involvement, with SIS:
Select all that apply: