American Association of Community Psychiatrists

Disclosure of Interests and Affiliations

Board of Directors

 

 

Name:                                                  ____________________Telephone: _________________________             

 

Address:                                                                                                                                              ________________

 

                                                                                                                ________________________________________

 

The AACP has adopted a conflict of interest policy and implementing procedures in order to ensure the integrity of its policies, positions, publications and other activities.  The identification of an interest below does not necessarily indicate that a member has a conflict of interest.  A member may still be able to participate in the activities of the Board if an identified interest creates an apparent or potential conflict, as long as the interest is disclosed and the board does not recommend recusal.  Please answer the following questions about your interests and affiliation to the best of your current knowledge. 

 

An interest is significant if it:

 

§               Provides cash, shares, and/or anything else of value (including gifts, travel, lodging, meals, goods and services) totaling $2,000 or more in value in a year;

§               Involves an ownership of shares, stock of other interest  of 5% or more of an entity; or

§               Derives from a position as director, trustee, proprietor, officer, managing partner, consultant, or employee.

 

                                                                                                                                               

 

Please answer each “Yes/No” question below and sign and date the statement at the end of this form.  If the answer to any of these questions is “Yes,” provide the information requested on additional sheets and attach them to this form, identifying the number of the question(s) to which the information provided applies.

 

1.        Do you or an immediate family member* have a significant interest in any business or organization that (a) provides goods or services to, or does any other business with, the AACP or which has sought to do so within the past three years or which seeks to do so in the future or (b) that competes with the AACP, its products or services?

 

 

1(a).              Yes         No           If yes, please provide complete information

 

1(a).               Sample Affirmative Answer:

                        Yes  X

                        Spouse owns management consulting firm that sought to provide consultation on employee benefits to AACP two years ago, and may compete to provide such services in the future.

 

 

 

 

 

 

 

 

1(b).              Yes          No           If yes, please provide complete information about interest(s).

 

1(b).               Sample Affirmative Answer:

                        Yes  X

                        I own $25,000 worth of stock in a professional publisher that produces psychiatric texts that may compete with AACP.

 

 

 

 

 

 

 

 

 

 

2.      Please list those sources that account for more than 5% of your professional income (e.g., private practice; consultation; employment by a clinic, HMO, hospital, medical school, etc.) and the names of the organizations from which the income is derived.

 

Sample Answer:

Private Practice of Psychiatry – 50%

Nursing home consultation – 10%

Teaching at University of Xanadu Medical School – 10%

Pharmaceutical industry-funded research, BQR Pharmaceuticals – 30%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.       Are you an officer, trustee or director of, or involved in public representation and advocacy (including lobbying) on behalf of any organization other than the AACP?

 

Yes                 No                 If yes, please give the name of each organization(s) and describe the activities in which you will be involved:

 

Sample Affirmative Answer:

Yes  X          

My daughter is executive director of the Association of Behavioral Health Carve-Outs

 

 

 

 

 

 

 

 

 

 

 

Statement of Compliance:  I have reviewed, and agree to comply with the AACP’s Conflict of Interest Policy and Procedures.  I have identified all interests and affiliations about which information has been requested and I agree to update this statement should these change.

 

                I understand that the Procedures require that if an issue arises in the course of the work of the Board on which I serve that creates a conflict or apparent conflict for me, I will identify my interest to the remaining members of the Board at the outset of the discussion.

 

 

 

                                                                                                                                                                                               

                Date                                                                                        Signature

 

                                                                                                                                                                                               

                                                                                                                Please print or type full name