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MIT Board Nomination – Conflict of Interest Disclosure Form

Home / MIT Board Nomination – Conflict of Interest Disclosure Form

MIT Board Nomination – Conflict of Interest Disclosures (2022-2024)

Conflict of Interest Disclosures

Name(Required)

First Last

Please choose one:(Required)

I have a direct financial interest or an indirect interest with an enterprise with which AAGP has an actual or potential transaction or arrangement. (Describe below)

I do not have a direct financial interest or an indirect interest with an enterprise with which AAGP has an actual or potential transaction or arrangement.

Describe the above interest:(Required)

Please choose one:(Required)

I have a compensation arrangement with AAGP (e.g., receive honorarium, receive fee for preparing course material, paid consultant).

I do not have a compensation arrangement with AAGP (e.g., receive honorarium, receive fee for preparing course material, paid consultant).

Describe the above:(Required)

Please choose one:(Required)

I do serve on the governing body, or as an officer or committee member of another society or association representing professional interests of geriatric psychiatrists.

I do not serve on the governing body, or as an officer or committee member of another society or association representing professional interests of geriatric psychiatrists.

Please describe the above:(Required)

Please choose one:(Required)

I do receive research or similar grants from a commercial entity with which AAGP has an actual or potential transaction or arrangement.

I do not receive research or similar grants from a commercial entity with which AAGP has an actual or potential transaction or arrangement.

Describe the above:(Required)

Please choose one:(Required)

I have other relationships, commitments, activities (including uncompensated activities) or financial or fiduciary interests that hold present, potential, or apparent conflicts of interest.

I do not have any other relationships, commitments, activities (including uncompensated activities) or financial or fiduciary interests that hold present, potential, or apparent conflicts of interest.

Describe the above:(Required)

Please list below all health-related companies, other than your primary employer or practice, from which you receive honoraria, grant support, or other compensation in which you do have a direct financial interest (own stock, etc.) and describe the relationship of that nature.(Required)

Consent(Required)

I certify the above to be true.

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