CONFLICT OF INTEREST DISCLOSURE & CONFIDENTIALITY AGREEMENT
Conflict of Interest. In accepting such position with ASHI, Individual makes a commitment to perform his/her duties honestly, responsibly and in good faith. ASHI recognizes that those selected to serve with the organization may have diverse financial and professional interests. Nonetheless, Individual agrees that he/she shall not use his/her position with ASHI for personal gain and shall exercise particular care that no detriment to ASHI results from conflicts between Individual’s interests and those of ASHI.
Individual acknowledges and agrees that a conflict of interest may exist when the interests or concerns of Individual, an immediate family member of Individual, or any other group affiliated with Individual, may be viewed as competing with the interests or concerns of ASHI. Individual further acknowledges and agrees that a conflict of interest may also exist if Individual, an immediate family member of Individual, or any other group affiliated with Individual has a financial interest in or may gain personally from a policy or activity that is directed by ASHI.
Any individual who believes he or she may have a conflict of interest shall disclose the nature of the potential conflict to ASHI. If ASHI, excluding the Individual who has the potential conflict of interest, determines that a conflict does exist, ASHI shall take steps necessary to ensure that the conflict does not adversely impact the organization. For example, if the conflict of interest is relevant to a matter requiring action by ASHI, the individual involved shall be excused from the room during the deliberation of the matter, and shall not vote on the matter. Further, the minutes of the relevant meeting shall reflect that the conflict of interest was disclosed and that the interested person was not present during the final discussion and did not vote.
Individual shall be furnished with a copy of this Confidentiality Agreement upon his/her assumption of duties with ASHI, and annually thereafter. At such time, he/she shall be required to submit a statement regarding the existence of any conflicts of interest. Further, Individual shall immediately notify ASHI if a conflict of interest should arise after the submission of the annual disclosure statement.
I hereby disclose, on behalf of myself and members of my family, the following with respect to persons or entities who or which are doing business with, are proposing to do business with, desire to do business with, or compete with the American Society for Histocompatibility & Immunogenetics:
Do you have anything to disclose?
If you are not currently employed, indicate N/A
I receive, or am being considered to receive, compensation (e.g., consulting fees, speaking or writing honoraria, research or institutional support - including unrestricted educational grants, equipment or services, or reimbursement of expenses) from the following:
I have an ownership interest / am a major shareholder in the following:
I have a business or a business agreement with the following:
I serve another (other than ASHI) organization in the general areas of interest to ASHI in the following capacity(ies):
Confidentiality of Material and Information
Individual recognizes and acknowledges that, by reason of his/her position in the organization, he/she will acquire and have access to the information pertaining to ASHI business, Board Meetings, methods and materials and, further, that certain of said information and material are of a proprietary, confidential and secret nature and are a valuable and unique assets of the organization (the “Confidential Information”). Individual agrees that he/she will not, both during and after his/her term, whether intentionally or otherwise, use to his/her own or another’s advantage or disclose in any manner or make available to any person, firm, corporation, association, or other entity any Confidential Information. Specifically excepted from this obligation of confidentiality is all information which (a) is of a general health care nature which the individual learns as a result of his/her affiliation with ASHI which promotes and encourages high quality health care, health care cost containment measures, efficiency of operations in connection with the delivery of health care and a more productive use of health care resources; (b) was in individual’s legitimate possession prior to receipt of such information from ASHI; (c) was independently developed by individual without reliance upon any confidential information; (d) was rightfully received from third parties without an obligation of confidentiality to ASHI; (e) is in the public domain through means other than by disclosure by ASHI; and/or (f) is disclosed pursuant to any judicial or government request, requirement or order provided that the individual takes reasonable steps to provide ASHI the ability to contest such request, requirement or order. The obligations of confidentiality set forth herein shall remain in effect for five (5) years following the effective date of this agreement.
Copyright Disclaimer: Individual acknowledges that the content of any materials produced for ASHI during the individual’s tenure on a board, committee or task force belongs to ASHI and ASHI holds the copyright on that content. (Content created by a speaker for use at the ASHI Annual Meeting or Regional Workshop does not fall under this blanket disclaimer.)
Modification and Waiver. This agreement may be altered, modified, or amended only by an instrument in writing executed by both Individual and ASHI.
Electronic Signature* By signing below, I attest that all of the submitted information is true and accurate.
Please indicate in which capacity you serve ASHI: (Board Member (indicate which position), Publication Editor (Indicate which publication), Committee Chair/Member (indicate which committee), ASHI Headquarters Staff
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