PRIVILEGED AND CONFIDENTIAL
Society of NeuroInterventional Surgery
Disclosure Statement of Potential Conflicts of Interest
By Officers, Board of Directors, Members of Committees or Task Forces or Senior Administrative Staff Members


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I hereby acknowledge that, as an officer, director, member of a committee or task force, journal editor, or senior administrative staff member of the Society of NeuroInterventional Surgery ("the Society"), I occupy a position of trust and that I am expected to act at all times in good faith with undivided loyalty to the Society, to avoid situations in which my personal and outside interests [1] conflict with my duty to the Society, and to act in such a manner as to avoid even the appearance of using my position to advance, in a way inconsistent with the purposes and interests of the Society, any private interest of mine or of any individual or entity with whom I have a significant relationship. I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional circumstances places me in the position of having a private interest which is in conflict with any interest of the Society or with my obligations to the Society, except perhaps with respect to the affiliations listed below. I invite any further review by the Society or any aspects of these affiliations. I will take necessary steps to resolve any actual, apparent, or potential conflicts of interest, such as avoiding participation in deliberations or voting on issues for which my other affiliations present an actual, apparent, or potential conflict of interest with the Society’s interests. If a serious conflict cannot be resolved through disclosure and recusal from debate and voting, I will voluntarily step down from my position in the Society for which such conflict exists.

[1]Outside Interests are defined to include financial and non financial relationships. Financial interests are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g. stocks, stock options or other ownership interest excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contractual research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities for which remuneration is received or expected. With respect to personal financial relationships, “contracted research” refers to research funding in which an institution receives a grant and manages grant funds an an individuals is the principal or named investigator on the grant. Relevant financial relationships are those personal financial relationships (in any amount) occurring in the last 12 months with a commercial entity producing health care goods or services and that individual also has control over educational content (planning or presenting) about the products or class of products of the commercial interest.

Describy any outside affiliations below.

Examples: Consultant, Advisory Board member, stockholder, owner, investigator or spokesperson for pharmaceutical or medical device equipment companies.

Examples: Trustee, American Board of Radiology; Chair, Harvard Medical School Department of Radiology.

Examples: Consultant, FDA or National Institutes of Health.

(officer, director or chair of a major committee)

Examples: Assistant Editor, New England Journal of Medicine

(Describe type of practice or other professional environment(s). Example: Private practice, Chicago, IL; Adjunct Associate Professor, Department of Radiology, Northwestern University Medical Center).

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