Research Division - Member Survey Application Disclosure

Thank you for your interest in conducting a survey of the Spine Intervention Society's membership.

You are asked to complete this Disclosure survey in accordance with the Society's Disclosure Policy. The purpose of the disclosure policy is to protect the interest of the Spine Intervention 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 Spine Intervention Society publications, manager of the Corporation, or individual member. 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 the implementation of a survey of the Society's membership.

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 Disclosure Policy - www.spinalinjection.org.

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

The Research Division chair will review your disclosure along with your application. Any conflict must have resolution prior to approval. If you become involved with any entity that may present a conflict during the course of your survey of Society members, you must update your disclosure.

Any refusal to disclose relevant financial relationships may result in the denial of your survey application.

Question Title

* 1. Please provide your name:

First Name

Last Name

Credentials

Question Title

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

Question Title

* 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 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)? No Relationship	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)? Yes
If Yes, indicate company and 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?	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? No 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? Yes
If Yes, indicate company and relationship:
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?	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? No Relationship	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? Yes
If Yes, indicate company and relationship:
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?	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? No Relationship	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? Yes
If Yes, indicate company and relationship:

Question Title

* 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.

None

Yes

If Yes, indicate company and relationship:

Question Title

* 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 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? No Relationship	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? Yes
If Yes, indicate company and relationship:
Are you presently a director or trustee of any other health care institution?	Are you presently a director or trustee of any other health care institution? No Relationship	Are you presently a director or trustee of any other health care institution? Yes
If Yes, indicate company and relationship:
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?	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? No Relationship	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? Yes
If Yes, indicate company and relationship:
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?	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? No Relationship	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? Yes
If Yes, indicate company and relationship:

Question Title

* 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
Gifts	Gifts None	Gifts Yes
Describe nature of gifts, favors, services, or other:
Favors	Favors None	Favors Yes
Describe nature of gifts, favors, services, or other:
Services	Services None	Services Yes
Describe nature of gifts, favors, services, or other:
Other	Other None	Other Yes
Describe nature of gifts, favors, services, or other:
None	None None	None Yes
Describe nature of gifts, favors, services, or other:

Question Title

* 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:

Yes

If Yes, describe the nature of the activities:

Question Title

* 8. I HEREBY AGREE to report to the Research Division Chair any situation which may develop during the course of the proposed survey of Spine Intervention Society members.

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.

Name

Date

Email Address

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

Please contact the Spine Intervention Society office at 415.457.4747 for additional information and questions.

The Corporation’s Disclosure Policy is available on the Society's website: www.spinalinjection.org.

Question Title

* 1. Please provide your name:

Question Title

* 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:

Question Title

* 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.

Question Title

Question Title

* 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:

Question Title

Question Title

* 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:

Question Title

* 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: