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Conflict of Interest Signature Page

Section 13 Conflict of Interest Policy

Section 15 Whistle Blower Policy

Conflict of Interest Policy– Voluntary Disclosure Statement

OKLAHOMA ACADEMY OF PHYSICIAN ASSISTANTS

I declare that if I have any direct or indirect financial interests, or any personal family, business relationship, or other relationships that conflict (or have the appearance of conflicting) with my duties, responsibilities, and exercise of independent judgment as an officer, employee, or agent of the Academy, as a chair or member of a committee, task force, or other body of the Academy, or as a representative of the Academy to other public, private, or governmental organizations, I shall voluntarily disclose that a conflict (potential or real) exists. I will also abstain from voting and leave the meeting during a vote concerning any such conflict. In addition, I will abstain from drafting any Academy policy statement or other Academy communication on the academy matter which could be influenced by the conflict and will take such other actions as may be deemed necessary or appropriate by the Academy’s Board of Directors under the circumstances then present to manage the conflict of interest.

Name(Required)

First Last

Date(Required)

Signature(Required)

CONSTITUENT ORGANIZATION Position(Required)

Committee

Director

Officer

Employee

This form is to be retained in Academy files for the duration of the member’s tenure plus an additional 3 years.