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ASET Code of Conduct & Conflict of Interest Form

ASET Code of Conduct

Please read ASET’s Code of Conduct and complete the below conflict of interest form.

Conflict of Interest Form

Name *

First

Last

Inside Information:

Neither I, nor members of my immediate family, have disclosed or used confidential information relating to ASET for personal profit or advantage. *

Yes
If none

If yes, please list:

Inside Gifts, Favors, Services & Entertainment

Neither I, nor members of my immediate family have accepted gifts, favors, services or entertainment [as defined in the ASET Code of Conduct] which might influence my judgment or actions concerning the business or mission of ASET. *

Yes
If none

If yes, please list:

Politics & Outside Interests

I have not made or authorized any political contribution or other prohibited or illegal payments with funds of ASET, nor have I done or authorized any act which to my knowledge is illegal or prohibited by the ASET Code of Conduct or the law, or which constitutes an irregularity. *

Yes
If none

If yes, please list:

Knowledge of Impropriety

I do not have direct knowledge of any ASET agent who has or might have authorized or committed any act which could or might be illegal or prohibited by the ASET Code of Conduct, and which has not been reported or disclosed so as to be commonly held knowledge among members of the Board of Trustees. *

Yes
No

If yes, please list:

Employment/Consulting

In the past year, I have been employed and/or consulted, with or without pay, by the following individuals and/or entities (please list):

Other Service

Are you currently serving on any national health care boards – other than boards of national public charities or private foundations in the health care field. *

Yes
If none

If yes, please list:

Conflict of Interest

Do you need to disclose any positions held with other neurodiagnostic organizations or companies, interest, including members of your immediate family, substantial business or investment holdings, stocks, bonds, securities, other transactions or affiliations with businesses and other organizations or those of family members, that could give rise to conflicts of interest and which might influence your judgment or actions concerning the business or mission of ASET. *

Yes
If none

If yes, please list:

Other

Please describe any other information concerning you or members of your immediate family, not requested in the preceding paragraphs, which may represent an actual or potential conflict of interest.

Agreement

I have read the ASET Code of Conduct and Conflict of Interest statements and understand their provisions. I have not violated any of those provisions and have disclosed any potential concerns. I do not have direct knowledge of any violations by other agents which have not already been disclosed. I fully intend to follow the standards set forth in these statements while serving as an Agent of ASET – The Neurodiagnostic Society.

Yes

Name *

Date *

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