Disclosure Form

OSTEOARTHRITIS RESEARCH SOCIETY INTERNATIONAL
CONFIDENTIAL DISCLOSURE STATEMENT
(Adopted by the Board of Directors, September 9, 2009)

I.    Introduction
This Conflict of Interest Policy (“the Policy”) governs conflicts of interest involving (i) members of the Board of Directors (“the Board”) and committees of the Osteoarthritis Research Society International (“the Society”), (ii) others to whom the Board has delegated significant decision-making authority (Editor-in- Chief and Associate Editors of Society publications), and (iii) staff of the Society (collectively, “Interested Persons”). The purpose of the Policy is to protect the Society’s interests when it has entered into or is contemplating entering into a transaction or arrangement that might benefit a private interest of an Interested Person. The Policy is intended to supplement but not replace any applicable state and federal laws governing conflicts of interest applicable to nonprofit.

II.    Definition of a “Conflict/Duality of Interest”
A conflict/duality of interest is defined as a situation in which an individual decision-maker has any impediment to being impartial and loyal, such as: (1) a personal, professional, business or volunteer position, responsibility, or interest; or 2) a conflicting duty to another entity where the individual’s allegiance may be split between the Society and another organization. An apparent conflict/duality is defined as a situation or relationship that may cause an observer to question whether there is an impediment to impartiality.

III.    Disclosure Statement

Disclosure of relationship over the last 12 months. This form should be updated two times per year.

Name (first name, last name)
Employer Position

2. Sources of Personal Income

Sources of Personal Income (salary information from primary employer is not required) – List companies from which you receive income (honoraria, speaker’s bureau, royalties, expert witness fees, advisory boards, expert witness fees, patents, copyrights, licenses or other intellectual property and indicate if they are involved in the development/manufacture/testing/marketing of a potential or current therapy for OA.

Source of Honoraria Indicate amount received within last year Management Plan Describe Areas Of Conflict Is this a current concern? Are these funds directed to you personally, or to your institution?
Describe Patent or Source of Royalty Indicate amount received within last year Management Plan Describe Areas Of Conflict Is this a current concern? Are these funds directed to you personally, or to your institution?
Company Name Indicate amount received within last year Indicate amount received within last year Management Plan Describe Areas Of Conflict Is this a current concern? Are these funds directed to you personally, or to your institution?
Company Name Describe Products Is company involved in development/manufacture/testing/marketing of potential or current therapy for OA? If Yes describe product Indicate amount received within last year Management Plan Is this a current concern? Are these funds directed to you personally, or to your institution?
Include any company related to OA research in which you own more than $10,000 in stock (excluding mutual funds.)

3. Research Grants/Contracts
 

Funding Agency Institution/Group/Title of Study Type? Management Plan Describe Areas Of Conflict

4. Non-Medical Industry Investments

Do you have any non-medical, including but not limited to stocks, bonds, options, or ownership or contractual relationships that might conflict with your duties/position with OARSI. Include any relationship with a company that has or might be considered for a business relationship with OARSI?

Company Name Investment/Relationship Indicate amount received within last year Management Plan

5. Duties or Relationships with Other Societies or Organizations

Do you hold a volunteer or paid leadership position in another society or organization? If yes, please specify below.

Name of Organization Duty/Role (No need to List Membership)
I acknowledge my agreement to the letter and spirit of the Code, and I agree to report to the OARSI Ethics Committee any possible conflicts of interest (other than those stated below) that may develop before completion of the next annual statement. I acknowledge that I have received a copy of the "OARSI Code of Ethics.
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