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Conflict of interest disclosure statement financial interest disclosure statement


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AMERICAN NURSES ASSOCIATION
CONFLICT OF INTEREST DISCLOSURE STATEMENT

FINANCIAL INTEREST DISCLOSURE STATEMENT
The American Nurses Association’s (ANA) Boards, Committees and Task Forces are involved in the development of standards, evaluation processes, marketing information, financial information, business plans and other confidential and proprietary information. To ensure that conflicts of interest do not arise among volunteers working with ANA’s Boards, Committees and/or Task Forces, hereinafter termed “Project”, volunteers are asked to review and complete the Conflict of Interest Disclosure Statement and, if necessary, the Financial Interest Disclosure Statement..
The following definitions and instructions are intended to provide guidance to volunteers who are completing the Conflict of Interest Disclosure Statement and the Financial Interest Disclosure Statement.
DEFINITIONS:

Conflicts of Interest” arise when a volunteer or a member of his or her immediate family (i.e., spouse/partner, daughter/son, brother/sister, father/mother) has either:




  1. a significant personal financial interest in, or business relationship with, an entity that may be affected by the outcome of the ANA project with which the volunteer will become or is involved, e.g., the volunteer’s spouse/partner owns a medical quality assurance consulting firm and the volunteer wants to advise on NDNQI; or




  1. a significant individual professional benefit that may arise as a result of the outcome of the ANA Project with which the volunteer will become or is involved, e.g., a university professor who is seeking a research grant on the aging workforce and will be developing survey questions on the same topic for ANA’s web site.

Conflicts of Interest may lead to an action, omission, or situation which compromises the objectivity of the ANA volunteer in the work of the Project. Both actual and perceived Conflicts of Interest must be disclosed, although such conflicts do not necessarily preclude appointment.

An ANA “Projectis the work of any ANA Board, Committee, or Task Force that implements or furthers the work of ANA and which may have an impact on commercial markets or academic standing. Examples include: NIDSEC, NDNQI advisory committee, the Reference Committee and a nursing standards committee.

Significant Financial Interests” (SFI) are anything of monetary value from a business entity including salary, payments for service, consulting fees, honoraria, equity ownership (stocks, options, notes, etc.) and royalty-bearing intellectual property rights (patents, copyrights, trademarks). Income from an entity or equity in an entity must be aggregated for the volunteer, volunteer’s spouse or significant other, or dependent children.

Equity ownership” in a company amounts to an SFI if it exceeds $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value and represents more than a five percent (5%) ownership interest. If a financial interest arises solely from an investment in a business through a mutual fund, pension, or other investment fund over which the individual has no control, it will not be considered an SFI.

A “significant individual professional benefit” is a benefit that would flow uniquely to a volunteer who will become or is involved with an ANA Project, such as having access to information in advance of the general academic community in a manner that would give the volunteer an unfair advantage of some sort.



INSTRUCTIONS:

The Conflict of Interest Disclosure Statement must be completed by all ANA nominees for appointment. An SFI that may reasonably appear to affect or be affected by the Project must be disclosed. If an SFI is acknowledged on the Conflict of Interest Disclosure Statement, a Financial Interest Disclosure Statement must be completed for each business entity in which an SFI exists. If no SFI is acknowledged on the Conflict of Interest Disclosure Statement, the Financial Interest Disclosure Statement does not need to be completed.



The ANA Board of Directors, at its sole discretion, will determine whether a disclosed financial interest is an SFI that appears to lead to a Conflict of Interest. If it determines that it does not, the decision will be noted and the Financial Interest Disclosure Statement will be retained in the ANA files. If the board determines additional review is warranted, such review will be initiated according to ANA policy. Similarly, the ANA Board of Directors will determine if a disclosed “significant individual professional benefit” appears to lead to a Conflict of Interest. Appointment decisions are within the sole discretion of the ANA Board of Directors.
AMERICAN NURSES ASSOCIATION


NAME OF PROJECT:      




X

CONFLICT OF INTEREST DISCLOSURE STATEMENT



I/my family members do not have a significant personal financial interest, or business relationship with an entity, that may be affected by the work associated with the ANA and this Project.



I/my family members do have a significant personal financial interest, or business relationship with an entity, that may be affected by the work of the ANA and this Project.



I will file a Financial Interest Disclosure Statement with the American Nurses Association.



I do not have a significant individual professional interest that may be affected by this Project on which I may participate.



I do have a significant individual professional interest that may be affected by this Project on which I may participate. That interest is described as follows:     




I/my family members do not have a significant personal financial interest, or business relationship with an entity, that may be affected by the work associated with the ANA and this Project.



Signature of the Nominee/Appointee:________________________________________
Printed Name:      
Date:      
AMERICAN NURSES ASSOCIATION
FINANCIAL INTEREST DISCLOSURE STATEMENT



NAME OF PROJECT:      




Volunteer’s Name:

     

Home Phone Number:

(with area code)

     

Home Address:

(Street, City, State, Zip)

     


Home E-Mail Address:

     

Employer:

     

Position Title:

     

Work Address:

(Street, City, State, Zip)

     


Work Phone Number:

(with area code)

     

WORK E-MAIL ADDRESS:

     

Employer’s Structure:

(√ one)

 Corporation  Partnership  Sole Proprietorship  Non-Profit

 Government Agency  Other- describe:     

Name of entity which volunteer’s association may be affected by ANA project:

     

Address of This Entity:

(City, State, Zip)

     

Do you hold a position of employment or other affiliation with this entity?

(√)

 YES  NO

If yes, what is the position? (√)

 Employee  Manager  Officer  Director  Partner  Trustee

 Owner  Other – describe:      


Describe the work of the entity and how it might be affected by this ANA Project with which you may become affiliated as a volunteer (e.g., will the entity sell any product or consult on any issue that is the subject of the ANA’s work on the Project):


     



Income anticipated for the next twelve months from the entity (√) :

(combine for volunteer, spouse/partner, and dependent children)




TYPE:

 Salary  Consulting Fee  Honorarium  Dividends

VALUE:

 Less than $10K  $10K- $50K  More than $50K

Equity - stock, real estate, other ownership (√):

(combine for investigator, spouse/partner and dependent children)



% OWNERSHIP:

 Less than 5%  5% - 25%  25% - 50%  More than 50%

VALUE:

 Less than $10K  $10K- $100K  More than $100K



NAME OF PROJECT:      
VOLUNTEER’S PRINTED NAME:     
VOLUNTEER’S SIGNATURE: ___________________________________DATE:     

For ANA Use:

___The financial interest is not significant and/or does not reasonably appear to lead to a Conflict of Interest which would bias the ANA organizational entity or Project’s work, standards, development, or business.


___The financial interest may be significant and may lead to an actual or perceived Conflict of Interest and is to be submitted to the ANA Board of Directors for additional review and determination.
Reviewer(s): _____________________________________________
_____________________________________________
Proposed Committee Appointment: ____________________________ DATE___________


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