CONFLICT OF INTEREST ACKNOWLEDGMENT AND DISLOSURE FORM by 0z8y0A

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									 CONFLICT OF INTEREST ACKNOWLEDGMENT AND DISLOSURE FORM

Thank you for volunteering your time and talent to the American College of Radiology. ACR’s
Board of Chancellors recently approved a new Conflict of Interest (COI) Policy and Disclosure
Form. These apply to all ACR activities, except the Clinical Research Center in Philadelphia.
That office maintains its own COI policy and disclosure form because of federal grant
regulations.

Please note you must disclose any financial interest (e.g., ownership in or compensation from an
entity with which ACR has a transaction or arrangement) that amounts annually to $10,000 or
more. To reach the $10,000 disclosure threshold, ACR policy combines any amounts you
receive with those paid to your spouse, domestic partner, dependent children or significant other.
The policy does not require you to disclose certain payments, e.g., income from serving on
advisory committees or review panels for public or nonprofit entities.

If you have any questions about the COI Policy, please call ACR’s Legal Office at
800.227.5463, ext. 4044. You can access the complete COI Policy online at
www.acr.org/VolunteerACR.

I have read the ACR conflict of interest policy set forth above and agree to comply fully with
its terms and conditions at all times during my service as an ACR officer, chancellor or as a
member of or staff to an ACR commission, committee or task force. If at any time following
the submission of this form I become aware of any actual conflict of interest, or if the
information provided below becomes inaccurate or incomplete, I will promptly notify the ACR
Designates in writing.

I do _____ do not____ have an actual conflict of interest


Please disclose and explain Actual Conflicts of Interest:




___________________________          _________
Signature                            Date

___________________________
Print Name

								
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