Declaration of conflict of interest

Form No: COR530
Approved: December 2016
Last Revised: October 2018
Version: v2

Introduction

Pursuant to the provisions of the ACEM Conflicts of Interest Policy (COR139) (the policy), all College members and other persons serving on a College entity, and staff are obligated to avoid and disclose ethical, legal, financial or other conflicts of interest involving the College.

Before completing this declaration, please ensure you have read the policy as from time to time updated by the Board. Pursuant to the provisions of the policy, all conflicts of interest, whether actual, potential or perceived, must be declared and reported to the College. If insufficient space, please attach any additional information.

Member details

Name*

First NameLast Name

ACEM ID*

Email*

example@example.com

Phone number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Relevant College entities

Please list all ACEM entities of which you are a member and/or College role(s) you hold (e.g. accreditation inspector):*

Nature of conflict(s) of interest

Pursuant to the requirements of the policy, please outline the nature of any conflict(s) of interest, whether actual, potential or perceived. If none, write ‘Nil’.*

Proposed management of conflict(s) of interest

Pursuant to the requirements of the policy, please outline the arrangements proposed to manage/resolve the conflict(s) of interest.*

Acknowledgement

I understand that from time to time matters may arise through my involvement in ACEM entities and the activities of the College that give rise to a conflict of interest, whether actual, potential or perceived. I acknowledge that in all cases it is my responsibility to be aware of and to declare all such conflict(s) of interest, and that these will be considered pursuant to the relevant College regulations, policies and procedures as applicable.

Signed:*

Date*