American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH, PhD Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
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American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,
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American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Elie Akl, MD, MPH, PhD
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
None
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsof
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Ot her(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Robert M. Centor, MD, MACP
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
Iexcludedactivitiesgreaterthan3yearsold
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Mary Ann Forciea MD MACP
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Raymond A Haeme
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Any other intellectual interests that you feel are relevant! D but have not been captured in Convey or above?
NO
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M
For the Scientific Medical Polic Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
Hematuria
Antibiotics
Any other intellectual interests that you feel are relevant! but have not been captured in Convey or above 7;
YES NO
□ �
□
□
DECLARATION ,----;
I certify that to my knowledge and bel· any changes.
Signature
/'/ ,/ ,...
e disclosed my financial and non-financial interests �6�ve �nd I will promptly disclose
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
nil
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Russell Harris
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☐
High flow nasal oxygen ☐ ☐
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☐
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Russell Harris Date December 24, 2019
Mar 18,201913:36:59EDTAmer icanCol legeofPhysiciansRussellHarris
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
asabove.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeof
American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Janet Jokela
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
noadditionalrelevantinfo
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Devan Kansagara
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
none
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Adam Obley
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☐
High flow nasal oxygen ☐ ☐
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☐
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
Noinformationtoreport
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
None
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
N/A
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.