COI Form - American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers

All AASM Volunteers must complete a Conflict of Interest (COI). Individuals who are on more than one committee, task force, or panel only need to complete each form once. However, some groups will be asked to update their COI throughout the year.

Committee/Advisory Panel/Task Force*

Please select all groups to which you are appointed.

AASM Member Number*

Name*

First Last

Email*

Institution/Organization*

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.*

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.

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Conflict of Interest Form 2020

Conflicts of Interest

Accreditation Committee
Accreditation Site Visitor
Advocacy Committee
AI in Sleep Medicine Committee
AMA CPT Advisors
AMA House of Delegates
AMA RUC Advisors
APM Task Force
APSS Program Committee
Behavioral Insomnia Guideline Task Force
Coding and Compliance Committee
COVID-19 Task Force
Diversity, Equity and Inclusion Committee
Education Committee
Fellow Member Review Panel
Gold Standard Panel - Adult
Gold Standard Panel - Pediatric
Guidelines Advisory Panel
Hypopnea Scoring Rule Task Force
ICSD-3 Revision Task Force
Innovative Fellowship Models Advisory Panel
Intersociety Collaborations Presidential Committee
JCSM Editors
Lifelong Learning Development Committee
Management of Inpatient SDB Guideline Task Force
Management of REM Behavior Disorder Guideline Task Force
MSLT & MWT Protocol Task Force
Payer Policy Review Committee
Pediatric Age/Weight Criteria for Pap Task Force
Political Action Committee
Public Awareness Advisory Committee
Public Safety Committee
OSA Outcomes Monitoring Tool Advisory Panel (ICON)
Quality Measures Task Force
RLS and PLMD Guideline Task Force
Scoring Manual Committee
Sleep Team Assemblies Committee
Sleep Medicine Fellowship Directors Council Steering Committee
Sleep Technologist and Respiratory Therapist Education Committee
Surgical Treatments for OSA Guideline Task Force
Technology Innovation Committee
Telemedicine Presidential Committee
Treatment of Extrinsic CRSWDs Guideline Task Force
Treatment of Narcolepsy and Other Hypersomnia Guideline Task Force