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American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Elie Akl, MD, MPH, PhD
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
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For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Date December 30, 2019
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Dec30,201905:47:07ESTAmer icanCol legeofPhysiciansElieAkl
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
Alliancef orHealt hPolicyandSyst emsResearch Grant/Contract Self $180 ,119.00
AmericanCollegeof Rheumatology Grant/Contract Self $96,276.00
Deut scheGesellschaf t f ürInt ernat ionaleZusammenarbeit (GIZ )GmbH Grant/Contract Self $1,275.00
eilNat ionalDeRecherchesScient if iques(CNRS) Grant/Contract Self $25,082.00
Facult yof MedicineMedicalPract icePlan(MPP),AmericanUniversit yof Beirut Grant/Contract Self $36,000 .00
Facult yof MedicineMedicalPract icePlan(MPP),AmericanUniversit yof Beirut Grant/Contract Self $18,000 .00
GlobalEvidenceSynt hesisInit iat ive Grant/Contract Self $255,550 .00
DisclosurePurpose:AnnualGovernanceDisclosure2019
RecipientName:Centerforsystematicreviewsofhealthpolicyandsystemsresearch(SPARK),AmericanUniversityof
RecipientType:InstitutionGrant/ContractDescription:EstablishingarapidresponseservicetoaddressrequestsfrompolicymakersforHPSRinLMICsinthe
Grant/ContractPurpose:Research Grant/ContractAmount:$180 ,119.00Grant/ContractValuationDate:04/05/2019 ContractStartDate:09/01/2016 ContractEndDate:12/18/2018AdditionalInformation:
RecipientName:AUBGRADEcenter RecipientType:InstitutionGrant/ContractDescription:Conductingsystematicreviewsforthe2020udpateoftheAmericanCollegeofRheumathology(ACR)gui
Grant/ContractPurpose:ResearchGrant/ContractAmount:$96,276.00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:08/01/2018 ContractEndDate:12/01/2020AdditionalInformation:
RecipientName:AUBGRADECenter,AmericanUniversityofBeirut(AUB) RecipientType:IndividualGrant/ContractDescription:SupportINASantéinTunisiaindevelopingthecapacitytoadaptclinicalpracticeguidelines
Grant/ContractPurpose:ResearchGrant/ContractAmount:$1,275.00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:07/01/2018 ContractEndDate:12/01/2018AdditionalInformation:
RecipientName:CenterforSystematicReviewsinHealthPolicyandSystemsResearch(SPARK)
RecipientType:InstitutionGrant/ContractDescription:Applyinganimpact-orientedapproachtosupport,protectandaddresstheneedsofHealthCareWorker
Grant/ContractPurpose:Research Grant/ContractAmount:$25,082.00Grant/ContractValuationDate:04/05/2019 ContractStartDate:01/01/2018 ContractEndDate:12/30 /2019AdditionalInformation:
RecipientName:ElieAkl RecipientType:IndividualGrant/ContractDescription:Developingamethodologyforverifyingtheaccuracyandcompletenessofconflictofinterestdisclos
Grant/ContractPurpose:ResearchGrant/ContractAmount:$36,000 .00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:07/01/2017 ContractEndDate:06/01/2019AdditionalInformation:
RecipientName:ClinicalResearchInstitute,AmericanUniversityofBeirut RecipientType:InstitutionGrant/ContractDescription:Intellectualconflictwhenconsideringtreatmentoptions(INCONFLICT)
Grant/ContractPurpose:ResearchGrant/ContractAmount:$18,000 .00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:02/01/2015 ContractEndDate:02/01/2017AdditionalInformation:
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Int ernat ionalLeagueAgainst Rheumat ism(ILAR) Grant/Contract Self $25,000 .00
Nat ionalInst it ut ef orHealt hResearch Grant/Contract Self $13,083.00
WorldHealt hOrganizat ion Grant/Contract Self $5,400 .00
AdditionalInformation:
RecipientName:Centerforsystematicreviewsofhealthpolicyandsystemsresearch(SPARK),AmericanUniversityof
RecipientType:InstitutionGrant/ContractDescription:HostingSecretariatfortheGlobalEvidenceSynthesisInitiative(GESI)
Grant/ContractPurpose:Research Grant/ContractAmount:$255,550 .00Grant/ContractValuationDate:04/05/2019 ContractStartDate:06/01/2016 ContractEndDate:06/01/2019AdditionalInformation:
RecipientName:AUBGRADEcenter RecipientType:InstitutionGrant/ContractDescription:Adaptationofthe2015AmericanCollegeofRheumatology(ACR)RheumatoidArthritisguidelinesforth
Grant/ContractPurpose:ResearchGrant/ContractAmount:$25,000 .00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:02/01/2017 ContractEndDate:02/01/2018AdditionalInformation:
RecipientName:ClinicalResearchInstitute(AUB) RecipientType:InstitutionGrant/ContractDescription:UpdatingCochranesystematicreviewsonanticoagulationinpatientswithcancer
Grant/ContractPurpose:ResearchGrant/ContractAmount:$13,083.00
Grant/ContractValuationDate: ContractStartDate:01/01/2018 ContractEndDate:12/31/2018AdditionalInformation:
RecipientName:ElieAkl RecipientType:IndividualGrant/ContractDescription:serveasaguidelinemethodologistfortheWHOguidelinesonAfricanTrypanosomiasis
Grant/ContractPurpose:ResearchGrant/ContractAmount:$5,400 .00
Grant/ContractValuationDate:04/05/2019 ContractStartDate:02/22/2019 ContractEndDate:03/30 /2019AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
None
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsof
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
part icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Jan02,202011:44:34ESTAmer icanCol legeofPhysiciansLauraBaldwin
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizations
DisclosurePurpose:AnnualStaffDisclosure2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Ot her(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Participationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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Jan02,202010:06:29ESTAmer icanCol legeofPhysiciansKateCarroll
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
AmericanCollegeof Physicians Employment Self -
T heBeasleyFirm,LLC Employment Spouse/Partner -
AdditionalInformation:
DisclosurePurpose:CGC/PMC/SMPC,Entry
Title:Manager,ClinicalPolicy PositionDescription:StartDate:08/26/2014 EndDate: AdditionalInformation:
Title:TechnologySpecialist PositionDescription:StartDate:09/01/2009 EndDate: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Robert M. Centor, MD, MACP
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
![Page 11: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/11.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Robert M. Centor, MD, MACP Date 1/9/20
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Jan23,202010:04:46ESTAmer icanCol legeofPhysiciansRobertCentor
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
Dynamed Consultant Self $1,000 .00
MDCalc Consultant Self -
Medscape Consultant Self -
NKF Consultant Self -
T heCurbsiders Consultant Self -
U.S.Department of Vet eransAf f airs Employment Self -
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2020
Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:
Year Amount T ype
2019 $1,000 .00 Estimated
AdditionalInformation:ReviewchaptersforDynamed-receive$500 perchapterreview
Category:Consultant ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Ontheadvisoryboard
Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:OccasionallyIwriteapieceandtheypaymeupto$1000
Category:Consultant ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:MemberofanNKFperformancemeasuredevelopmentcommittee
Category:Consultant ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Appearasaguestdiscussantontheirpodcast
Title:Physician PositionDescription:Inpatientwardattending3.5monthseachyearStartDate:07/01/1993 EndDate: AdditionalInformation:
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
Iexcludedactivitiesgreaterthan3yearsold
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Jun24,201917:41:49EDTAmer icanCol legeofPhysiciansDouglasDeLong
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptlydiscloseanychanges.
DisclosurePurpose:ANNUALGOVERNANCEDISCLOSURE2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Jan14,202011:39:30ESTAmer icanCol legeofPhysiciansSarahDinwiddie
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
AmericanCollegeof Physicians Employment Self -
smartworkingmom.com OtherBusinessOwnership Self -
T ownSport sInt ernat ional Employment Spouse/Partner -
AdditionalInformation:
DisclosurePurpose:AnnualStaffDisclosure2020
Title:Associate,PerformanceMeasurement PositionDescription:Assisttheclinicalpolicydepartmentintheexecutionofallperformancemeasurement-relatedactivities
StartDate:11/14/2014 EndDate: AdditionalInformation:
FormofBusinessDescription:Educationalresourceofferingprovenstrategiesonhowtobuildanonlinebusinessandmonetizeitforpassiveincome
OwnershipCategory:FounderPartnershipCategory:InvestmentAmount:$1,000 .00
InvestmentAmountValuationDate:01/14/2020 AnnualCompensation:AdditionalInformation:
Title:FitnessManager PositionDescription:ManagethepersonaltrainingprogramsforPhiladelphiaSportsClubeswithinthePAregion
StartDate:09/01/2013 EndDate: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Mary Ann Forciea MD MACP
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
![Page 18: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/18.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Mary Ann Forciea MD MACP Date 1/9/2020
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Dec24,201915:35:15ESTAmer icanCol legeofPhysiciansMaryForciea
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
Cent erf orMedicareServices Grant/Contract Self -
Nat ionalBoardof MedicalExaminers Consultant Self -
PerelmanSchoolof Medicine,Universit yof Pennsylvania Employment Spouse/Partner -
PerelmanSchoolof Medicine,Universit yof Pennsylvania Employment Self -
T heRalst onCent er FiduciaryOfficer Self -
T IAA-CREFInst it ut e Stock Self -
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2019
RecipientName:UniversityofPennsylvania RecipientType:InstitutionGrant/ContractDescription:DemonstrationProject-IndependenceatHome
Grant/ContractPurpose:Other-HealthServicesResearchGrant/ContractAmount:
Grant/ContractValuationDate:05/03/2019 ContractStartDate: ContractEndDate:06/30 /2020AdditionalInformation:
Category:Consultant ConsultantDescription:StartDate:08/01/2005 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:
Title:ProfessorofPediatrics PositionDescription:FacultyStartDate:07/01/1980 EndDate: AdditionalInformation:
Title:ClinicalProfessorofMedicine PositionDescription:ClinicalFacultyStartDate:07/01/2000 EndDate:06/28/2019 AdditionalInformation:
OfficialTitle:Member,BoardofManagers PositionDescription:BoardMemberCompensationType:Unpaid OtherCompensation:StartDate:05/01/2006 EndDate:AnnualCompensation:AdditionalInformation:
PercentageOwnership: EstimatedValue:ValuationDate: DivestmentDate:AdditionalInformation:Retirementaccount
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Raymond A Haeme
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
![Page 22: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/22.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Date: Jan 3. 2020
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Jan03,202015:39:11ESTAmer icanCol legeofPhysiciansRayHaeme
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
DisclosurePurpose:AnnualGovernanceDisclosure2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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YES
Point of Care Ultrasound! □
High flow nasal oxygen! □
Any other intellectual interests that you feel are relevant! D but have not been captured in Convey or above?
NO
�
M
For the Scientific Medical Polic Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
Hematuria
Antibiotics
Any other intellectual interests that you feel are relevant! but have not been captured in Convey or above 7;
YES NO
□ �
□
□
DECLARATION ,----;
I certify that to my knowledge and bel· any changes.
Signature
/'/ ,/ ,...
e disclosed my financial and non-financial interests �6�ve �nd I will promptly disclose
/ ✓t'
Date (1t�tm\i/ 2021) ·
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Jan09,202017:51:07ESTAmer icanCol legeofPhysiciansPeterHamilton
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)
DisclosurePurpose:AnnualGovernanceDisclosure2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
nil
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Russell Harris
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
![Page 30: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/30.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☐
High flow nasal oxygen ☐ ☐
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☐
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Russell Harris Date December 24, 2019
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Mar 18,201913:36:59EDTAmer icanCol legeofPhysiciansRussellHarris
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptlydiscloseanychanges.
DisclosurePurpose:AnnualGovernanceDisclosure2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Dec28,201921:27:54ESTAmer icanCol legeofPhysiciansGregoryHood
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
DisclosurePurpose:AnnualGovernanceDisclosure2019
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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American College of Physicians
Department of Clinical Policy
Disclosure of Interests: Supplement
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests
that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines
Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
Name: UA.d!w-
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Jan13,202017:04:33ESTAmer icanCol legeofPhysicianslindahumphrey
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
Upt oDat e Consultant Self $3,000 .00
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2020
Category:Consultant ConsultantDescription:StartDate:01/01/2010 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:
Year Amount T ype
2019 $3,000 .00 Estimated
AdditionalInformation:Iwriteachapteronlungcancerscreeningandreceiveroyaltiesthattypicallyarearound3kperyear
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
asabove.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeof
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
Physician’sAnt i-Harassment Policy.
Yes
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American College of Physicians Department of Clinical Policy
Disclosure of Interests: Supplement
Name: Janet Jokela
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting. Thank You. If in doubt, err on the side of full disclosure
![Page 41: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/41.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Janet Jokela Date 01/09/2020
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Jan22,202012:46:33ESTAmer icanCol legeofPhysiciansJanetJokela
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy
Value
AAMC,Ent rust ableProf essionalAct ivit iesCoreWorkingGroup,UnivILCollegeof Medt eam(member)
Other Self -
AmericanBoardof MedicalSpecialt ies,Commit t eeonCert if icat ion(COCERT )member Other Self -
AmericanCollegeof Physicians Other Self $15,000 .00
ChampaignCount yAudubonBoardmember Other Self -
MississippiValleyRegionalBloodCent er FiduciaryOfficer
Self -
Universit yof Illinoisat Urbana-Champaign Employment Spouse/Partner -
Universit yof IllinoisCollegeof Medicineat Urbana-Champaign Employment Self -
DisclosurePurpose:January2020 GovernanceDisclosure
Category:Other ConsultantDescription:StartDate:07/01/2014 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
Category:Other ConsultantDescription:StartDate:03/01/2017 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
Category:Other ConsultantDescription:StartDate:01/22/2020 EndDate: CompensationType:CashOtherCompensation: AnnualCompensation:
Year Amount T ype
2020 $15,000 .00 Estimated
AdditionalInformation:MKSAPDeputyEditor
Category:Other ConsultantDescription:StartDate:02/01/2000 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
OfficialTitle:Boardmember PositionDescription:serveasamemberoftheMVRBCBoardasafiduciaryofficer
CompensationType:Unpaid OtherCompensation:StartDate:02/01/2018 EndDate:AnnualCompensation:AdditionalInformation:
Title:Professor PositionDescription:FoundersProfessor,CollegeofEngineering,DepartmentofComputerScience
StartDate:08/15/1999 EndDate: AdditionalInformation:
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VAIllianaHealt hcareCent er Employment Self -
IntellectualProperty
T ype IsLicensed Int erest HeldBy Value
OtherInt ellect ualPropert y-Nat ionalAcademyof Medicine,st andingcommit t ee... - Spouse/Partner -
OtherInt ellect ualPropert y-NSF,pediat ricvaccineresearch,endedAugust 20 - Spouse/Partner -
OtherInt ellect ualPropert y-NSF,BroaderImpact Init iat ive;AirForceOf f ice... - Spouse/Partner -
AdditionalInformation:
Title:ActingRegionalDean PositionDescription:ChiefAcademicandFiduciaryOfficerfortheregionalcampusoftheUniversityofIllinoisCollegeofMedicineinUrbana
StartDate:02/16/2017 EndDate: AdditionalInformation:myprimaryemployment
Title:InfectiousDiseaseconsultant PositionDescription:StartDate:02/01/2000 EndDate: AdditionalInformation:
Description:NationalAcademyofMedicine,standingcommitteeCDCStrategicNationalStockpile(member)
IncomeSource:
YearlyIncome: AdditionalInformation:
Description:NSF,pediatricvaccineresearch,endedAugust2017 IncomeSource:YearlyIncome: AdditionalInformation:
Description:NSF,BroaderImpactInitiative;AirForceOfficeofScientificResearch,ended02/2018
IncomeSource:NSF
YearlyIncome: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
noadditionalrelevantinfo
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Devan Kansagara
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
![Page 46: American College of Physicians Department of Clinical ... · American College of Physicians Department of Clinical Policy Disclosure of Interests: Supplement Name: Elie Akl, MD, MPH,](https://reader035.vdocuments.mx/reader035/viewer/2022081522/5ee097c8ad6a402d666bc10f/html5/thumbnails/46.jpg)
For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☒
High flow nasal oxygen ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Date
1/9/20
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Jan13,202013:44:06ESTAmer icanCol legeofPhysiciansDevanKansagara
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
DisclosurePurpose:committeemembership
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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Jan13,202019:27:50ESTAmer icanCol legeofPhysiciansRachaelLee
SummaryofFinancialInterests
IntellectualProperty
T ype IsLicensed Int erest HeldBy Value
OtherInt ellect ualPropert y-Honoraria - Self $5,000 .00
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2020
Description:Honoraria IncomeSource:YearlyIncome:Amount T ype Year Payment Receipt
$5,000 .00 Actual 2019 DirectPayment
AdditionalInformation:Honorariaforwebinarandlivemeetingoninfluenza
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
IdidonewebinarandonelivemeetingoninfluenzaforPrimeEducationLLCthatisnotrelatedtoworkforACP
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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AmericanCollegeofPhysiciansDepartmentofClinicalPolicy
DisclosureofInterests:Supplement
Name:MauraMarcucci
Purpose:Thisisasupplementaldisclosureofinterests(DOI)worksheettoreportanyintellectualinterests
thatarerelevanttoclinicaltopicsontheagendafortheupcomingClinicalGuidelines
Committee/PerformanceMeasurementCommittee/ScientificMedicalPolicyCommitteemeeting.
ThankYou.
Ifindoubt,erronthesideoffulldisclosure
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FortheClinicalGuidelinesCommittee:Inthelast3years,haveyouoranyhouseholdmemberspublishedonanyofthefollowingtopicareas?Pleaseincludebothpeer-reviewedandnon-peer-reviewedsources(e.g.newspaperop-ed;blog)
YES NO
PointofCareUltrasound � �
Highflownasaloxygen � �Anyotherintellectualintereststhatyoufeelarerelevant
buthavenotbeencapturedinConveyorabove?� �
FortheScientificMedicalPolicyCommittee:Inthelast3years,haveyouoranyhouseholdmemberspublishedonanyofthefollowingtopicareas?Pleaseincludebothpeer-reviewedandnon-peer-reviewedsources(e.g.newspaperop-ed;blog)
YES NO
Hematuria� �
Antibiotics� X
Anyotherintellectualintereststhatyoufeelarerelevant
buthavenotbeencapturedinConveyorabove?
� �
DECLARATION
IcertifythattomyknowledgeandbeliefthatIhavedisclosedmyfinancialandnon-financialinterestsaboveandIwillpromptlydiscloseanychanges.
Signature DateJanuary5th,2020
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Jan25,202012:50:04ESTAmer icanCol legeofPhysiciansMauraMarcucci
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
CanadianInst it ut esof Healt hResearch Grant/Contract Self $380 ,000 .00
EuropeanCommission Grant/Contract Self -
McMast erUniversit y Employment Self -
Networkof CanadianEmergencyResearchers Other Spouse/Partner -
PSIFoundat ion Grant/Contract Self $230 ,000 .00
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2019,AnnualGovernanceDisclosure2020
RecipientName:MauraMarcucci RecipientType:IndividualGrant/ContractDescription:Granttosupportatrialoninterventionstoreducepostoperativedeliriumandcognitiveoutcome
Grant/ContractPurpose:ResearchGrant/ContractAmount:$380 ,000 .00
Grant/ContractValuationDate: ContractStartDate:10 /01/2019 ContractEndDate:AdditionalInformation:
RecipientName:Fondaz ioneIRCCSCa'Granda,Milan,Italy RecipientType:InstitutionGrant/ContractDescription: Grant/ContractPurpose:Grant/ContractAmount: Grant/ContractValuationDate:01/25/2020ContractStartDate:05/01/2015 ContractEndDate:04/30 /2018 AdditionalInformation:
Title:AssistantProfessor PositionDescription:StartDate:07/01/2017 EndDate: AdditionalInformation:
Category:Other ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
RecipientName:MauraMarcucci RecipientType:IndividualGrant/ContractDescription:CareerAward Grant/ContractPurpose:ResearchGrant/ContractAmount:$230 ,000 .00 Grant/ContractValuationDate:01/05/2020ContractStartDate:03/01/2020 ContractEndDate:02/28/2023 AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
none
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Jun26,201906:47:37EDTAmer icanCol legeofPhysiciansRobertMcLean
SummaryofFinancialInterests
Ent it y T ype Int erest HeldBy Value
Nort heast MedicalGroup Employment Self -
AdditionalInformation:
Certification
Icertifythattomyknowledgeandbeliefthattheforegoingdisclosureoffinancialandintellectualinterestsiscompleteandtruthful,andIwillpromptly
DisclosurePurpose:annualdisclosure
Title:EmployedPhysician PositionDescription:Physician&MedicalDirectorofClinicalQualityStartDate:11/01/2012 EndDate: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
AmericanCollegeofRheumatologyQualityofCareCommitteetermwasNov2015-Nov2018ABIMRheumatologySub-specialtyBoardtermwasApril2014-June2018
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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discloseanychanges.
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Dec26,201917:52:40ESTAmer icanCol legeofPhysiciansAdamObley
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
Advent ist Healt hPort land Other Self $2,500 .00
Cent erf orEvidence-basedPolicy Employment Self -
MedicalSociet yof Met ropolit anPort land FiduciaryOfficer Self -
MilbankMemorialFund Travel Self $10 ,000 .00
Nat ionalConf erenceof St at eLegislat ures Travel Self $1,000 .00
Port landVAMedicalCent er Employment Self -
Schoolof Medicine,OregonHealt handScienceUniversit y Employment Self -
AdditionalInformation:
DisclosurePurpose:AnnualGovernanceDisclosure2019
Category:Other ConsultantDescription:StartDate:09/26/2018 EndDate:09/26/2018 CompensationType:CashOtherCompensation: AnnualCompensation:
Year Amount T ype
2018 $2,500 .00 Actual
AdditionalInformation:Speakinghonorarium
Title:ClinicalEpidemiologist PositionDescription:CEbPsupports0 .5FTEStartDate:08/01/2014 EndDate: AdditionalInformation:
OfficialTitle:Trustee PositionDescription:TrusteeCompensationType:Unpaid OtherCompensation:StartDate:08/01/2015 EndDate:AnnualCompensation:AdditionalInformation:
Location(s):Variousmeetingsandstateworkshops(asfaculty) TravelStartDate:01/01/2015 TravelEndDate:06/01/2019EstimatedValue:$10 ,000 .00 ValuationDate:12/26/2019Purpose:FacultyforEvidence-informedHealthPolicyWorkshops AdditionalInformation:
Location(s):Nashville,TN TravelStartDate:05/05/2018 TravelEndDate:05/07/2018EstimatedValue:$1,000 .00 ValuationDate:12/26/2019Purpose:FacultyforEvidence-informedHealthPolicyWorkshop AdditionalInformation:
Title:StaffPhysician PositionDescription:DivisionofGeneralMedicine,DepartmentofHospitalandSpecialtyMedicine
StartDate:07/01/2013 EndDate: AdditionalInformation:
Title:AssociateProfessorofMedicine PositionDescription:Facultyappointment,notcompensatedStartDate:07/01/2013 EndDate: AdditionalInformation:
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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American College of Physicians
Department of Clinical Policy Disclosure of Interests: Supplement
Name: Adam Obley
Purpose: This is a supplemental disclosure of interests (DOI) worksheet to report any intellectual interests that are relevant to clinical topics on the agenda for the upcoming Clinical Guidelines Committee/Performance Measurement Committee/Scientific Medical Policy Committee meeting.
Thank You.
If in doubt, err on the side of full disclosure
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For the Clinical Guidelines Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Point of Care Ultrasound ☐ ☐
High flow nasal oxygen ☐ ☐
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☐
For the Scientific Medical Policy Committee: In the last 3 years, have you or any household members published on any of the following topic areas? Please include both peer-reviewed and non-peer-reviewed sources (e.g. newspaper op-ed; blog)
YES NO
Hematuria ☐ ☒
Antibiotics ☐ ☒
Any other intellectual interests that you feel are relevant but have not been captured in Convey or above?
☐ ☒
DECLARATION
I certify that to my knowledge and belief that I have disclosed my financial and non-financial interests above and I will promptly disclose any changes.
Signature Date
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Dec03,201915:33:28ESTAmer icanCol legeofPhysiciansAmirQaseem
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
AmericanCollegeof Physicians Employment Self -
Cent ersf orDiseaseCont rolandPrevent ion Other Self -
Cochrane Other Self -
Dynamed Other Self -
Dynamed Other Self -
GRADEWorkingGroup Other Self -
MeasuresApplicat ionPart nership Other Self -
MedBiquit ous Other Self -
DisclosurePurpose:ClinicalPolicy,test
Title:VicePresident PositionDescription:ClinicalPolicyStartDate:12/07/2003 EndDate: AdditionalInformation:
Category:Other ConsultantDescription:StartDate:01/01/2016 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates
Category:Other ConsultantDescription:StartDate:06/01/2019 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
Category:Other ConsultantDescription:StartDate:07/01/2014 EndDate: CompensationType:OtherOtherCompensation:honorarium AnnualCompensation:AdditionalInformation:
Category:Other ConsultantDescription:StartDate:01/01/2013 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonotknowtheexactstartdate.
Category:Other ConsultantDescription:StartDate:01/01/2003 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonothavetheexactstartdate
Category:Other ConsultantDescription:StartDate:01/01/2014 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonotremembertheexactstartdate.
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Nat ionalAcademiesof Sciences,Engineering,andMedicine Other Self -
Nat ionalQualit yForum Other Self -
Nat ionalQualit yForum Other Self -
Nat ionalQualit yForum Other Self -
PCPI Other Self -
PCPI Other Self -
RIGHT WorkingGroup Other Self -
T homasJef f ersonUniversit y Other Self -
Women'sPrevent iveServicesInit iat ive Other Self -
Category:Other ConsultantDescription:StartDate:01/01/2013 EndDate:01/01/2019 CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:Donothaveexactstartorenddates
Category:Other ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates
Category:Other ConsultantDescription:StartDate:01/01/2019 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates
Category:Other ConsultantDescription:StartDate:01/01/2018 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates
Category:Other ConsultantDescription:StartDate:01/01/2015 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Don'thavetheexactstartdate
Category:Other ConsultantDescription:StartDate:01/01/2017 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactstartdate
Category:Other ConsultantDescription:StartDate:01/01/2015 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Donothaveexactstartdate
Category:Other ConsultantDescription:StartDate:01/01/2014 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:Idonothavetheexactstartdate
Category:Other ConsultantDescription:StartDate:01/01/2017 EndDate: CompensationType:OtherCompensation: AnnualCompensation:AdditionalInformation:
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AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
Category:Other ConsultantDescription:StartDate:05/01/2016 EndDate: CompensationType:UnpaidOtherCompensation: AnnualCompensation:AdditionalInformation:don'thavetheexactdates
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
No.
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Jan13,202016:54:01ESTAmer icanCol legeofPhysiciansJeffShafiroff
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
AmericanCollegeof Physicians Employment Self -
AdditionalInformation:
Certification
DisclosurePurpose:ClinicalPolicyCommitteesACPStaff
Title:SeniorAnalyst PositionDescription:StartDate:11/07/2016 EndDate: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
Noinformationtoreport
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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Jan13,202016:38:32ESTAmer icanCol legeofPhysiciansPatriciaSiemion
SummaryofFinancialInterests
Idonothaveanyfinancialintereststodiscloseatthistime.
AdditionalInformation:
Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizations
DisclosurePurpose:AnnualStaffDisclosure2019,AnnualStaffDisclosure2020
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement bet weenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Participationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
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Jan10,202009:33:04ESTAmer icanCol legeofPhysiciansFarahSultan
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
AmericanCollegeof Physicians Employment Self -
SigmaHeat hConsult ingLLC Other Self -
AdditionalInformation:
DisclosurePurpose:AnnualStaffDisclosure2019
Title:ResearchAssociate PositionDescription:Provideclinicalinputonevidencereviews,guidelines,performancemeasures,andhighvaluecaretopics.LeadScientificMedicalPolicyCommittee(SMPC),andsupporttheworkoftheSMPC,andother
StartDate:02/06/2016 EndDate: AdditionalInformation:
Category:Other ConsultantDescription:StartDate:05/16/2019 EndDate:12/16/2019 CompensationType:CashOtherCompensation: AnnualCompensation:AdditionalInformation:Part-timecontractposition(inactive)
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
None
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orce,AnnalsofInternalMedicineedit orialst af f orot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof anACPboard,commit t ee,council,chapt erleadership,t askf orceorot hergovernancegroupaspart of ACP’sannualgovernancedisclosureprocess?
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Jan18,202020:07:12ESTAmer icanCol legeofPhysiciansJenniferYost
SummaryofFinancialInterests
CompanyorOrganizat ion
Ent it y T ype Int erest HeldBy Value
CanadianInst it ut esof Healt hResearch Grant/Contract Self $9,310 ,000 .00
CanadianInst it ut esof Healt hResearch Grant/Contract Self $22,600 .00
CanadianInst it ut esof Healt hResearch Grant/Contract Self $226,000 .00
CanadianInst it ut esof Healt hResearch Grant/Contract Self $22,450 .00
EvidenceBasedResearchNetwork FiduciaryOfficer Self -
EvidenceSynt hesisInt ernat ional FiduciaryOfficer Self -
McMast erUniversit y Employment Self -
SigmaT het aT auInt ernat ional FiduciaryOfficer Self -
DisclosurePurpose:AnnualGovernanceDisclosure2020
RecipientName:Dr.MichaelMcGillion RecipientType:IndividualGrant/ContractDescription:TheSMArTVIEW,CoVeRed Grant/ContractPurpose:ResearchGrant/ContractAmount:$9,310 ,000 .00 Grant/ContractValuationDate:10 /15/2015ContractStartDate:10 /15/2015 ContractEndDate:09/30 /2019 AdditionalInformation:
RecipientName:Dr.SandraCarroll RecipientType:IndividualGrant/ContractDescription:FollowingtheC-SPINRoadmap:Realiz ingMeaningfulPatientEngagement
Grant/ContractPurpose:ResearchGrant/ContractAmount:$22,600 .00
Grant/ContractValuationDate:03/01/2016 ContractStartDate:03/01/2016 ContractEndDate:02/28/2018AdditionalInformation:
RecipientName:Dr.MichaelMcGillion RecipientType:IndividualGrant/ContractDescription:THESMArTVIEW,CoVeRed Grant/ContractPurpose:ResearchGrant/ContractAmount:$226,000 .00 Grant/ContractValuationDate:03/01/2016ContractStartDate:03/01/2016 ContractEndDate:02/28/2018 AdditionalInformation:
RecipientName:Dr.SandraCarroll RecipientType:IndividualGrant/ContractDescription:PrEPARE:PreparingforMeaningfulPatientEngagementatthePopulAtionHealthREsearch
Grant/ContractPurpose:ResearchGrant/ContractAmount:$22,450 .00
Grant/ContractValuationDate:03/01/2016 ContractStartDate:03/01/2016 ContractEndDate:02/28/2017AdditionalInformation:
OfficialTitle:SteeringCommitteeMember PositionDescription:CompensationType: OtherCompensation:StartDate:10 /01/2016 EndDate:AnnualCompensation:AdditionalInformation:
OfficialTitle:Secretariat PositionDescription:OrganizeandsupportactivitiesoftheorganisationCompensationType: OtherCompensation:StartDate:03/01/2018 EndDate:AnnualCompensation:AdditionalInformation:
Title:AssistantProfessor PositionDescription:StartDate:06/01/2010 EndDate:06/30 /2017 AdditionalInformation:
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Universit yof Bologna Other Self $5,213.19
VillanovaUniversit y Employment Self -
AdditionalInformation:
OfficialTitle:President-AlphaNuChapter PositionDescription:President-AlphaNuChapterCompensationType: OtherCompensation:StartDate:09/01/2019 EndDate:08/31/2021AnnualCompensation:AdditionalInformation:
Category:Other ConsultantDescription:StartDate:11/16/2019 EndDate:11/22/2019 CompensationType:CashOtherCompensation: AnnualCompensation:
Year Amount T ype
2019 $5,213.19 Actual
AdditionalInformation:GuestLecturer
Title:AssociateProfessor PositionDescription:StartDate:08/22/2017 EndDate: AdditionalInformation:
1. Pleasespecif yanyaddit ionalinf ormat ionwhichyouconsiderrelevant t ot hisdisclosure.
N/A
2. ACPrequiresyourannualaf f irmat iont oabidebyit sDisclosureof Int erest sandManagement of Conf lict sPolicy,Non-DisclosureAgreement ,Int ellect ualPropert yPolicy,andAnt i-Harassment Policyifyou'resubmit t ingyourdisclosurest oACPasamemberof anACPgovernancegrouporasCollegest af f ,aspart of ACP'sannualdisclosureprocess.
a. Areyousubmit t ingyourdisclosurest oACPasamemberof oneof t hef ollowinggroups:ACPboard,commit t ee,council,t askf orce,and/orot hergovernancegroup?Chapt erCouncilorot herChapt erleadershiprole?Nat ionalorchapt erst af f ?Annalsof Int ernalMedicineedit orialst af f ?Other(meet ingguest s,cont ract ors,aut hors,et c.)
Yes.
i. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sDisclosureof Int erest sandManagement of Conf lict sPolicy.
Yes
ii. I,t heundersigned,ent erint ot heNon-DisclosureAgreement betweenmyself andt heAmericanCollegeof Physicians,whichgovernst hedisclosureandf urnishingof ACP'smembersof t heBoardof Regent s,Boardof Governors,Commit t ees,Councils,Governors-elect andChapt erPersonnelinanysuchWorkGroupof ACP,wit hinf ormat iondevelopedf orACP,deemed"Propriet aryInf ormat ion."
Yes
iii. I,t heundersigned,int endingt obelegallybound,herebydeclareandagreet ot ermsofpart icipat ionint heACPGroupact ivit iesof ACPasspecif iedint heACPInt ellect ualPropert yPolicy.
Yes
iv. I,t heundersigned,acknowledgeIhavereadandagreet oabidebyt heAmericanCollegeofPhysician’sAnt i-Harassment Policy.
Yes
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Certification
Bysubmittingthisform,IattestthatIhavedisclosedallinterestsrelatedtohealthcarefromthelast3yearsonbehalfofmyselfandanyhouseholdmembers,includingconsiderationofinterestsinthefollowingareas:
Researchandconsultingsupport(e.g.,grants,contracts,sponsorships,honoraria,oranyotherfeesrelatedtoroleasconsultant,speaker’sbureauparticipation,orexpertaspartofregulatory,legislative,orjudicialprocess)Investmentsandproprietaryinterestsexcludingbroadlydiversifiedinvestmentssuchasmutualorpensionfunds(e.g.,stocks,bonds,stockoptions,commercialbusinessinterests,patents,trademarks,copyrights)Membershiponboards,workgroups,panels,orcommitteesthroughothermedicalsocietiesorhealthcareorganizationsParticipationinadvocacyorlobbyingactivities,includinganyrolesorrelationshipswithdiseaseadvocacyorganizations
Otheraspectsofmybackgroundorpresentinterestsnotaddressedabovethatmightbeperceivedasaffectingmyobjectivityorindependence