Annual Conflict of Interest Disclosure | Indiana District 9 Healthcare Coalition

Conflict of Interests Disclosure Form

A conflict of interest, or an appearance of a conflict, can arise whenever a transaction, or an action, of the District 9 Hospital Emergency Planning and Preparedness Committee, Inc. conflicts with the personal interests, financial or otherwise, of a board member, or an immediate family member of a board member, or the board member’s employer (collectively “your personal interests”).

Name*
First Last
Please describe below any relationships, transactions, or positions you hold (volunteer or otherwise), or circumstances that you believe could create a conflict of interest, now or in the future, between the District 9 Hospital Emergency Planning and Preparedness Committee, Inc. and your personal interests, financial or otherwise:*
- I have no conflict of interests to report.
- I have the following conflict of interests, or potential conflicts of interests, to report:
1.
2.
3.
I have reviewed the District 9 Hospital Emergency Planning and Preparedness Committee, Inc. conflict of interests policy and I understand that it is my obligation to disclose a conflict of interests, or appearance of a conflict, to the chair of the board when a conflict, or appearance of a conflict, arises, and that for transactions in which I have a conflict, I will abstain from any vote on the matter involving the conflict.*
Signature:
Today's Date*
MM slash DD slash YYYY