DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS OR …



Volunteer ApplicationPlease complete the volunteer application and disclosure form and submit both forms with your current curriculum vitae or brief bio as a SINGLE PDF DOCUMENT to Mara Lang at membership@. The closing date to submit your application is January 4, 2021. NameDateInstitution/Practice NameStreetApt/SuiteCityStateZipEmail Address2194625024000Please list the committees/areas of interest in order of preference32552641211600Are you currently a member of any ASBrS committees? 23774401077000If yes please list the committee name(s) 3255264942300How many ASBrS annual meetings have you attended? left32287400Are you a representative to another organization (ABS, CoC, NAPBC, etc.)?left27002700Please briefly state your qualifications, experience, areas of expertise, etc.American Society of Breast SurgeonsDISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS OR NON-FINANCIAL/STRATEGIC BUSINESS RELATIONSHIPS OR PARTNERSHIPS4299049158200Name: 28592079973300Committee/Working Group/Representative Group: 3175548640? No, I (or my spouse/partner) do not any relevant financial relationships or non-financial/strategic business relationships or partnerships with any commercial interests as it pertains to my position in the American Society of Breast Surgeons.? Yes, I (or my spouse/partner) do have a relevant financial relationship(s) or non-financial/strategic business relationship(s) or partnership(s) with a commercial interest(s) as it pertains to my position in the American Society of Breast Surgeons.relationship(s) or partnership(s) with a commercial interest(s) as it pertains to my position in the American Society of Breast Surgeons.00? No, I (or my spouse/partner) do not any relevant financial relationships or non-financial/strategic business relationships or partnerships with any commercial interests as it pertains to my position in the American Society of Breast Surgeons.? Yes, I (or my spouse/partner) do have a relevant financial relationship(s) or non-financial/strategic business relationship(s) or partnership(s) with a commercial interest(s) as it pertains to my position in the American Society of Breast Surgeons.relationship(s) or partnership(s) with a commercial interest(s) as it pertains to my position in the American Society of Breast Surgeons.The American Society of Breast Surgeons has implemented a disclosure process to ensure that anyone in a leadership position within the organization has disclosed to us all relevant financial interests and nonfinancial/strategic business relationships or partnerships with any commercial interests.List the names of proprietary entities producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies with which you or your spouse/partner have, or have had, a financial or non-financial business relationship within the past 24 months. For this purpose, we consider any business relationships of your spouse or partner to be yours.List what you or your spouse/partner received (eg, salary, honorarium, etc) and specify your or your spouse/partner's role.Check box below attesting that you will adhere to the Conflict of Interest Policy.? I will adhere to the Conflict of Interest Policy and disclose any conflict of interest that may arise and recuse myself from any final decisions where a potential bias could exist as it pertains to my position in the American Society of Breast mercial InterestNature of Relevant Financial Relationship(Include all those that apply)What I or spouse/partner received*My or spouse/partner role**Example: Company ‘X’HonorariumSpeaker*What was received: Financial benefits, including salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest, (eg, stocks, stock options or other ownership interest, excluding diversified mutual funds), etc. Non-financial incentives, including equipment, disposable supplies, paid trainings, paid vacations, etc.**My or Spouse/Partner Role(s): Employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities.Glossary of TermsCommercial InterestA company or commercial interest is a for-profit entity that develops, produces, markets, or distributes drugs, devices, services or therapies used to diagnose, treat, monitor, manage, and alleviate health conditions. This definition is not intended to include non-profit entities, entities outside of the healthcare sector, or entities through which physicians provide clinical services directly to patients.Financial and strategic business relationships or partnershipsFinancial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected.A strategic business relationship or partnership is a relationship between two commercial enterprises, usually formalized by one or more business contracts. A strategic partnership will usually fall short of a legal partnership entity, agency, or corporate affiliate relationship.Non-financial and strategic business relationships or partnershipsNon-financial relationships are those relationships in which the individual benefits by receiving incentives or transactions which does not involve financial benefits. For example, non-financial incentives transactions could include but not limited to: prizes, paid training, gift cards, paid vacations, paid parking or transit passes.Relevant financial relationshipsASBrS focuses on financial relationships with commercial interests in the 24-month period preceding the time that the individual assumes a volunteer or staff role. ASBrS has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. ASBrS defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 24 months that create a conflict of interest.584835939800040520379108400Signature Date ................
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