Conflict of Interest Disclosure Form

In their capacity as leaders of AMIA, all individuals have an obligation to make decisions and conduct affairs of the organization based upon the desire to promote AMIA and its mission. AMIA’s policy aims to educate leaders on what constitutes a conflict of interest or the appearance of a conflict of interest, to set standards for full disclosure of professional and relevant personal activities and relationships that created a conflict of interest or the appearance of a conflict of interest, to remedy and resolve conflicts of interest per AMIA’s conflict of management options, and to encourage leaders to remain aware of and take initiative to manage, disclose, and resolve conflicts of interest appropriately.

AMIA’s Complete Conflict of Interest Policy includes a table which describes preferred ways the AMIA Executive Committee suggests individuals manage COI. Individual should complete this online form using these preferred methods. If the suggested management option should not apply, the individual should indicate why with detailed information. The AMIA Executive Committee will confirm their agreement with, or recommend change to, the appropriate management option.

In order to proactively address any potential conflicts of interest, each leader is required to annually complete and submit a disclosure form. Disclosures and agreed to methods of management are summarized yearly on the internal AMIA website allowing all AMIA members to review the COI disclosures of leaders.

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