Board Member Agreement (BMA) - American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers

Board Member Agreement and Conflict of Interest Form

Board of Directors

Name*
First Last
Email*
Institution/Organization*
Role with AASM
In the last year, have you reviewed the current mission and vision statements?*
- YES
- NO
In the last year, have you reviewed the current AASM bylaws?*
- YES
- NO
In the last year, have you reviewed the current AASM policy manual?*
In the last year, have you reviewed the current AASM policy manual?
- YES
- NO
If you answered “NO” to any questions above, you must review said document before proceeding.
Signature*
I certify that the information provided is current and correct and that I am in compliance with American Academy of Sleep Medicine policy regarding Board Member Agreements.
Conflicts of Interest
Please respond to the following questions as they pertain to your roles in all AASM Board, Committee, Advisory Panel and Task Forces you have been appointed to.

Definitions:
Advisory Board: A group of individuals appointed to provide strategic advice to the leadership of a commercial (for-profit) or nonprofit organization; may also be called a council or panel
Board of Directors: A group of individuals, elected to represent a profit or nonprofit organization’s shareholders/members, who are responsible for setting the strategic direction for the organization and have overall responsibility for the activities and finances of the organization
Commercial entity: For-profit manufacturers, marketers and/or vendors of products and services
Consultant: A professional who provides expert advice in a specialized field or topic
Healthcare association: a nonprofit, professional or patient membership organization, focused on healthcare, that individuals pay dues to join
Intellectual Property:A work or invention that is the result of creativity, such as a manuscript or a design, to which one has rights and for which one may apply for a patent, copyright, trademark, etc.
Sleep Entity: Sleep Laboratory, Sleep Facility or Independent Sleep Practice.
Speakers’ Bureau: A group of experts who are recruited and trained by a commercial entity to deliver information about the commercial entity’s products and/or services to others in their field
Are you directly employed or serving as a consultant of a commercial entity (work related to sleep) where the total yearly non-investment income is ≥$25,000?*
- YES
- NO
For each conflict, provide the name of the company, start date (month/year) and end date (month/year or current).*
Are you directly employed or serving as a consultant of a commercial entity (work related to sleep) where the total yearly non-investment income is <$25,000?*
- YES
- NO
For each conflict, provide the name of the company, start date (month/year) and end date (month/year or current).*
If multiple conflicts are listed, is the combined total yearly non-investment income from all of the conflicts listed above ≥$75,000 per year?*
- YES
- NO
Are you, a spouse, domestic partner or dependent in ownership of more than 5% of a sleep-related commercial entity?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Do you have knowledge of a close family member owning more than 5% of a sleep-related commercial entity?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Are you, a spouse, domestic partner or dependent in ownership of individual stock in a sleep-related commercial entity?*
- YES
- NO
For each conflict, provide the name of the company, start date (month/year), end date (month/year or current) and indicate if the value is ≥$10,000.*
Have you accepted payments for speaking engagements from a commercial entity, except from an unrestricted educational grant or an ACCME accredited (or similar) program?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Have you received a personal gift or an institutional gift on your behalf or discounted or free use of materials or equipment from a commercial entity of value ≥$1,000?*
- YES
- NO
For each conflict, provide the name of the company, type of gift/free use, start date (month/year) and end date (month/year or current).*
Are you directly employed or serving as a consultant related to establishment or accreditation of sleep entities?*
- YES
- NO
For each conflict, provide the name of the company, start date (month/year) and end date (month/year or current).*
Are you a member of a paid or unpaid Board of Directors or Advisory Board of a commercial entity (for profit) related to sleep medicine, excluding AASM SleepTM?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Are you a member (paid or unpaid) of a Board of Directors or Medical Advisory Board of another professional medical society or other healthcare association related to sleep medicine?*
- YES
- NO
For each conflict, provide the name of the professional medical society or other healthcare association, start date (month/year) and end date (month/year or current).*
Are you a member (paid or unpaid) of a commercial entity’s speaker’s bureau?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Have you received a research or travel grant from a commercial entity of value ≥$1,000?*
- YES
- NO
For each conflict, provide the name of the commercial entity, start date (month/year) and end date (month/year or current).*
Are you a partial or sole owner of intellectual property related to sleep medicine that produces income or other monetary benefit?*
- YES
- NO
For each conflict, list the type of intellectual property, start date (month/year), end date (month/year or current) and indicate if the total yearly income or other monetary benefit is ≥$10,000 per year.*
I have read the American Academy of Sleep Medicine Policy on Conflicts of Interest and certify that the information provided is current and correct and that I am in compliance with the American Academy of Sleep Medicine policy. I agree to inform the AASM immediately should any of the information change.*
Conflict of Interest Signature*
I have read the American Academy of Sleep Medicine Policy on Conflicts of Interest and certify that the information provided is current and correct and that I am in compliance with the American Academy of Sleep Medicine policy. I agree to inform the AASM immediately should any of the information change.
Clicking the “Submit” button serves as your digital signature below.

Board Member Agreement and Conflict of Interest Form

Conflicts of Interest