American Pharmacists Association Disclosure Statement & Confidentiality Statement
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Name:
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APhA Office:
Academy Officer
President
Speaker HOD
Treasurer
Trustee
Other
Please respond fully to each question
1)
State name (s) and address (es) of each employer (s), your position(s), and title (s):
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2)Describe your work activities and specifically note and conflicts that may exist relative to the work you do / or will do for APhA:
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3) Does your employer have any business or financial dealings with APhA?
Yes
No
Don't Know
If you answered Yes to number 3, please describe in detail:
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4) Do you receive any money from APhA for services rendered, such as honoraria, consulting fees, payments for writing, etc.?
No
Yes (amount / description)
if yes, state amount and what services are rendered (Do not include any expense reimbursements)
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5) Do you hold any office in any national or state pharmacy-related organization or regulatory body?
No
Yes (organization / office held/ term of office)
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6) Do you serve as a consultant or advisor to any pharmacy-related organization (including PBMs, HMOs, etc), pharmaceutical manufacturer, or third party administrator?
No
Yes (organization / nature of service)
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7) Do you know of any factors or circumstances related to your service to APhA on the one hand and any other activities engaged in on the other hand that may create an actual or potential conflict of interest between these activities?
No
Yes (describe the details)
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8) Affirmation Statement: I recognize that, in the course of participating as a volunteer leader for APhA, I will be exposed to confidential and proprietary information belonging to APhA regarding APhA and its activities, including proprietary information regarding APhA initiatives and positions.
I pledge to keep such information confidential and promptly raise any questions or concerns I have in this regard with the APhA General Counsel.
My checking the Yes box below affirms the above statement and that I have provided complete and accurate information on thi form and that I understand the association's conflict of interest policies and procedures.
Yes
No
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Indicates Response Required