Duality or Conflict of Interest Disclosure Form

Duality or Conflict of Interest Disclosure Form Policy

In consideration of the AAO’s policy and the Participant’s position with the AAO, each Participant shall complete, sign and date the following disclosure form on an annual basis and shall update it if and when any change in the information occurs.

Duality or Conflict of Interest Disclosure Form

For AAO Trustees, Staff, Council and Committee Members, and other Volunteer Leaders.

The American Association of Orthodontists (“AAO”) recognizes that Trustees, AAO staff/employees, members of AAO councils and committees, task forces, and other volunteer leaders within the AAO have diverse professional and financial interests.  Because of these interests, the Board of Trustees has adopted a policy whereby all Trustees, AAO staff and employees, AAO council/committee/task force members, and other volunteer leaders within the AAO (hereinafter collectively referred to as “Participants”) must disclose all relationships which could potentially influence the way Participants carry out their AAO responsibilities, especially in matters related to their outside interests.  It is essential that all Participants adhere to this policy in order to protect the reputation and integrity of the AAO.  Failure to adhere to this policy could result in a real or apparent conflict or duality of interest, including personal financial gain, if Participants have significant relationships with not-for-profit or for-profit organizations/ commercial enterprises (hereinafter collectedly referred to as “Organizations”) whose products, services, or businesses are related to the goals of the AAO.

It is important to be clear that not every outside interest held by a Participant constitutes a  duality or conflict of interest. In reality, most such outside interests will never develop into a conflict or duality of interest. However, it is crucial that Participants disclose all interests (defined below) in outside Organizations so that any potential conflict or duality of interest can be ascertained, and appropriate corrective steps can be taken. The AAO thanks you for your understanding in the importance of this process, and for your assistance in completing this disclosure form.

Disclosures:

Certain relationships with other Organizations could lead to actual, perceived, or apparent dualities or conflicts of interest. The Board of Trustees has determined that the following relationships between Participants and Organizations should be disclosed to the AAO. Involvement with an Organization in the following circumstances extends to the Member’s spouses/partners and dependents, and covers any involvement during the past 12 months, whether or not still current.  The relationships are as follows:

• Consulting fees/honoraria including honoraria from a third party, gifts or in-kind compensation for consulting, lecturing, travel, scientific advisory board service, legal testimony or consultation, or other purpose. 
• Speaker’s bureau 
• Paid consultancies, paid advisor roles, or any other role in which the individual receives compensation (monetary or any other financial benefit) in exchange for providing advice or consultation to a company or association
• Unpaid consultancies, unpaid advisor roles, or any other role in which the individual provides advice or consultation to a company or association, although not in exchange for compensation
• Equity interests/stock options (or entitlement to the same), including a non-publicly traded company, in any healthcare-related company other than your own practice.
• Equity interests (or entitlement to the same) in a publicly traded and financially related company, in any healthcare-related company other than your own practice.  
• Royalty income or the right to receive future royalties. 
• Non-royalty payments or entitlements to payments in connection with the activity that are not directly related to the reasonable costs of that activity.
• Officer, trustee, director, or any other fiduciary role, whether or not remuneration is received for service.
• Ownership/partnership/principal excluding mutual diversified funds. 
• Research grants from a financially interested company.
• Fellowship support  
• Salary or position funding (partial or full) or “in-kind” support of program. 
• Intellectual property rights including patent or other intellectual property in a forprofit corporation. 
• Other financial benefit (please specify)

If you are aware of any other relationship with an organization that might be perceived by others as potentially influencing your objectivity in any AAO matters in which you are involved, please disclose such relationship pursuant to the procedures described below.

Procedure for Annual Duality or Conflict of Interest Disclosure Form:

Participants are required to electronically file a signed Disclosure Form not less than annually and on such other occasions as requested by the Board of Trustees.

Participants have a continuing obligation to disclose any potential conflict or duality of interest with respect to any issue, transaction or other matter that affects or may affect the AAO.  In other words, notwithstanding the submission of the attached Disclosure Form, Participants must reveal any potential duality or conflict of interest that arises after the submission of this form.  Each subsequent disclosure must describe the nature of the real, perceived, or potential conflict or duality of interest and all facts known relating to the subject matter.

The form will be reviewed by the AAO Legal staff and the Trustee liaison and/or Chair for each pertinent Participant role to determine whether any disclosures constitute a duality or conflict of interest. The Board of Trustees shall have the right to inquire further with regard to your disclosure and, in the event it determines there to be a duality or conflict or appearance of a duality or conflict of interest, or in the event of a failure to provide requested information or otherwise to cooperate with it, shall make a determination as to your continuing role and participation as a Trustees, AAO staff or employee, AAO council/committee/task force member, or other volunteer leader within the AAO.  The existence of a relationship as defined above does not necessarily imply ineligibility to serve, but rather that participation in some matters may be modified or avoided or, in appropriate circumstances, discontinued.  The Board of Trustees shall have the authority, as it deems appropriate, to make the final decision as to your continuing role and participation in the AAO.

The responsibility for identifying a potential conflict resulting from a relationship with an organization in any given situation rests with the Participant.  If you have any questions as to whether or not there is a conflict, whether actual, potential, or perceived, you should first address the matter with the General Counsel or Associate General Counsel of the AAO. When your work with the AAO involves a matter relating to an organization with which you have a relationship, appropriate corrective action will be determined, and you will be informed of any steps you should take to avoid any influence from the duality or conflict of interest.

Duality and Conflict of Interest Disclosure Form:

Please complete the electronic form by the due date given (example below). If you do not have a relationship with an organization as defined in this policy, please read and check the appropriate box on the Disclosure Form.

If you have a relationship with an organization as defined above, please read and check the appropriate box on the Disclosure Form, and describe the potential conflict.