2024/2025 ACHA Conflict of Interest Disclosure Declaration:

Please review this page for further details on COI policies and here to access the PDF policy set forth by the Board of Directors.

Please Check One:*

I affirm that I have read and understand the ACHA Conflict of Interest Policy, and understand that, as an ACHA volunteer leader, it is my obligation to act in a manner that promotes and protects the best interests of ACHA, and to avoid conflicts of interest when making decisions and taking actions on behalf of ACHA.

Do you have a Conflict of Interest Relationship?*

If your answer is "yes", please provide the information requested below. The ACHA Executive Office will safeguard and limit access to the information you disclose about other business relationships. If your answer is "no", please proceed to the bottom of the form and provide your electronic signature and today's date.

To the extent that I have served in any of the following capacities for any company, organization, or other entity or person over the past 12 months, or anticipate doing so in the next 12 months, I hereby disclose individually (a) the type of relationship; (b) the identity of the organization, company, or other relevant entity or person involved; (c) a description of the activity sufficient to allow the ACHA Board of Directors to make a determination as to the existence of a conflict of interest; and (d) the financial compensation status (i.e. yes/no). I shall also disclose any other direct and indirect (e.g. through a close family member or a business associate) business, professional, or personal situations and relationships that might influence, or that might be perceived to influence, my judgement or actions relative to my service for ACHA, during the past 12 months and anticipated during the next 12 months. I agree.

(a) Type of Relationship: (Please select only one type. Each disclosure requires a separate form.)
(d) Are you financially compensated?

I understand that it is my responsibility to update this information if there are any changed circumstances, including new relationships or activities, as they occur or arise. I also understand that in the course of my service to ACHA, I may have access to confidential or other non-public information. I agree not to disclose this information, or make any use of this information, except as necessary to perform my duties for ACHA. By typing my name below, I am affirming that it represents my electronic signature and that I approve of all the information entered in this Conflict of Interest Disclosure Form. I further attest that all submitted information is accurate. I have identified all potential conflicts of interest. For those conflicts of interest that could bias my leadership role(s), I agree to abide by the resolution of conflict as determined by the ACHA Board of Directors (or Executive Committee on behalf of the Board of Directors). Please type your First Name Below: *

Optional Additional Comments: