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

Skip to content

Contact | Patient Info | Foundation JOIN Today Login with AMSSalesforce

Clinical Resources
- Practice Standards
  Practice Guidelines
  Endorsed Guidelines
  Guideline Development Process
  Guidelines in Development
  Consensus Statements and Papers
  Quality Measures
  Volunteer
- Coding and Reimbursement
  MACRA
  MIPSwizard
  AMA CPT and RUC
  Sleep Medicine Codes
  Telemedicine Codes
  Coding FAQ
  Other Coding Resources
  Medicare Resources
  Medicare Policies
  Medicaid Resources
- Col 3
  COVID-19 Resources
  Provider Fact Sheets
  Patient Information
  Journals
  Telemedicine
  EHR Integration
  #SleepTechnology
- AASM Scoring Manual
  
  The definitive reference for the evaluation of polysomnography (PSG) and a home sleep apnea test (HSAT), outlining rules, terminology and technical specifications.
Professional Development
- Choose Sleep
  The Path to Sleep Medicine
  Sleep Physician Profile
  Get Involved in Sleep Medicine
  Choose Sleep Interest Group
  Sleep Medicine Elective Toolkit
  Sleep Medicine Resources
  Sleep Medicine Webinars
  AIRE Pilot Programs
- Mentor/Sleep Team Training
  AASM Mentor Program
  Mentees
  Mentors
  Sleep Team Training
  Advanced Practice Registered Nurses and Physician Assistants (APRN PA)
  Accredited Sleep Technologist Education Program (A-STEP)
  Inter-scorer Reliability (ISR)
  Coding Education Program (A-CEP)
- Col 3
  Annual Meeting
  Career Center
  Case Study of the Month
  Compensation Survey
  State Sleep Societies
  Continuing Medical Education (CME)
  Maintenance of Certification (MOC)
  Young Investigators Research Forum (YIRF)
  Talking Sleep Podcast
- Events
  
  Learn new ideas and best practices for professional growth. View descriptions and register for our upcoming live courses!
Membership
- Individual/Facility Membership
  Individual Membership
  Benefits
  Categories
  Members-Only Resources
  FAQs
  Facility Membership
  Benefits
  FAQs
- Advocacy
  Current Online Campaigns
  Donate
  AASM Political Action Committee
  Payer Policy Scorecards
  Payer Advocacy
  Position Statements
  Sleep Health Champions
  AMA House of Delegates
  State Policy Directory
  High School Video Contest
- Col 3
  Leadership Election
  Montage
  Membership Directory
  Volunteer Opportunities
  Committees
- Sleep Team Assemblies
  
  Online communities for non-physician, AASM members to network with and learn from colleagues with similar professional backgrounds.
Accreditation
- Types of Accreditation
  Sleep Facility
  Independent Sleep Practice
  Durable Medical Equipment
- Resources
  FAQ
  Reference Materials
  Products and Services
- Col 3
  Choose AASM Accreditation
  Special Application Types
  Accreditation Verification
  Contact Us
- Apply or Renew
  
  AASM accreditation demonstrates a sleep medicine provider’s commitment to high quality, patient-centered care through adherence to these standards.
About
Store
Search for:

Clinical Resources
- Practice Standards
  Practice Guidelines
  Endorsed Guidelines
  Guideline Development Process
  Guidelines in Development
  Consensus Statements and Papers
  Quality Measures
  Volunteer
- Coding and Reimbursement
  MACRA
  MIPSwizard
  AMA CPT and RUC
  Sleep Medicine Codes
  Telemedicine Codes
  Coding FAQ
  Other Coding Resources
  Medicare Resources
  Medicare Policies
  Medicaid Resources
- Col 3
  COVID-19 Resources
  Provider Fact Sheets
  Patient Information
  Journals
  Telemedicine
  EHR Integration
  #SleepTechnology
- AASM Scoring Manual
  
  The definitive reference for the evaluation of polysomnography (PSG) and a home sleep apnea test (HSAT), outlining rules, terminology and technical specifications.
Professional Development
- Choose Sleep
  The Path to Sleep Medicine
  Sleep Physician Profile
  Get Involved in Sleep Medicine
  Choose Sleep Interest Group
  Sleep Medicine Elective Toolkit
  Sleep Medicine Resources
  Sleep Medicine Webinars
  AIRE Pilot Programs
- Mentor/Sleep Team Training
  AASM Mentor Program
  Mentees
  Mentors
  Sleep Team Training
  Advanced Practice Registered Nurses and Physician Assistants (APRN PA)
  Accredited Sleep Technologist Education Program (A-STEP)
  Inter-scorer Reliability (ISR)
  Coding Education Program (A-CEP)
- Col 3
  Annual Meeting
  Career Center
  Case Study of the Month
  Compensation Survey
  State Sleep Societies
  Continuing Medical Education (CME)
  Maintenance of Certification (MOC)
  Young Investigators Research Forum (YIRF)
  Talking Sleep Podcast
- Events
  
  Learn new ideas and best practices for professional growth. View descriptions and register for our upcoming live courses!
Membership
- Individual/Facility Membership
  Individual Membership
  Benefits
  Categories
  Members-Only Resources
  FAQs
  Facility Membership
  Benefits
  FAQs
- Advocacy
  Current Online Campaigns
  Donate
  AASM Political Action Committee
  Payer Policy Scorecards
  Payer Advocacy
  Position Statements
  Sleep Health Champions
  AMA House of Delegates
  State Policy Directory
  High School Video Contest
- Col 3
  Leadership Election
  Montage
  Membership Directory
  Volunteer Opportunities
  Committees
- Sleep Team Assemblies
  
  Online communities for non-physician, AASM members to network with and learn from colleagues with similar professional backgrounds.
Accreditation
- Types of Accreditation
  Sleep Facility
  Independent Sleep Practice
  Durable Medical Equipment
- Resources
  FAQ
  Reference Materials
  Products and Services
- Col 3
  Choose AASM Accreditation
  Special Application Types
  Accreditation Verification
  Contact Us
- Apply or Renew
  
  AASM accreditation demonstrates a sleep medicine provider’s commitment to high quality, patient-centered care through adherence to these standards.
About
Store
Search for:

Clinical Resources
Professional Development
Membership
Accreditation
About
Store

COI Form2020-06-10T08:07:53-05:00

Conflict of Interest Form

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.
Are you directly employed or serving as a consultant of a commercial entity?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below including total combined yearly noninvestment income*
Are you, a spouse, or children in ownership of more than 5% of a sleep-related commercial entity OR stock in a sleep-related commercial entity of a value greater than $10,000?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Have you accepted payments for speaking engagements from a commercial entity, except from an unrestricted educational grant or an ACCME accredited program?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Have you received personal gifts, institutional gifts on your behalf, or discounted or free use of material or equipment from a commercial entity of value ≥$1,000?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Are you a member of a paid or unpaid board of directors or advisory board of a commercial entity or another professional organization related to sleep medicine?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Are you a member of a commercial entity’s speaker’s bureau?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Have you received a research or travel grant from a commercial entity?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
Are you a partial or sole owner of intellectual property related to sleep medicine that produces income or other monetary benefit?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below (Provide total yearly income or other monetary benefit):*
Do you provide consulting services related to the establishment or accreditation of sleep entities?*
- YES
- NO
Provide full details of all such arrangements, including the entity, type of activity, dates of activity and amount of compensation below:*
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.

2510 North Frontage Road
Darien, IL 60561
Phone: (630) 737-9700
Fax: (630) 737-9790

About

Events

Patient Information

News

Professional Development

Affiliated Sites

AASM Foundation

Journal of Clinical Sleep Medicine

Sleep Education

Copyright © 2020 American Academy of Sleep Medicine | Sitemap| Terms & Conditions| Privacy

My Account
Logout