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Education & Groups
American Board of Applied Toxicology (ABAT)
2025 ABAT Election Ballot
ABAT Travel Grant
ABAT Exceptional Service Award
ABAT Newsletter
Sitting for the American Board of Applied Toxicology Exam
ABAT Examination Study Guide
Certification Renewal Documents
Life Long Learning Articles (LLSA)
ABAT Member Directory
Diplomate Verification
ABAT Board of Directors Contact Information
AACT Antidote Collective
E-Learning
Research Seminar: The Nuts and Bolts of Toxicology Research
Advanced Hazmat Life Support Training
TOXISMO Society for the Discussion of Scientific Literature
ToxNow
Webinars
ABAT Journal Club Webinars
COVID Webinar Series
Toxicology Residency & Fellowship Training Programs
Clinical Toxicology Guidelines Collaborative
Recommendations
ToxCoach Mentorship Program
Committees
AACT Committee Leadership Opportunities
Sections
Acute & Intensive Care
Addiction Toxicology Section
Clinical Toxicology In Sports
Diversity, Equity, and Inclusion Section
Herbs & Dietary Supplements
Geriatric Toxicology
Occupational / Environmental
Envenomations
Forensic
Pediatric
Weapons of Mass Destruction
Toxicology History
Radiation
Trainee and Student
Student Chapters
National Clintox Book Club
Webinars
NACCT Annual Meeting
Abstract Submissions
Meeting Information
Register
After the Fact CE
Research Grants
AACT Research Award
AACT Knowledge Translation Grant Award
Junior Investigator Research Grant
Gary S. Wasserman, DO, FAACT Memorial Pediatric Abstract Award
Toxicology Trainee Research Grant
Student and Trainee Travel Award
Lampe-Kunkel Memorial Award
Resources
Event Calendar
Publications
Clinical Toxicology Journal
Question of the Day
News
Current Awareness in Clinical Toxicology
Toxicology Today
Out of Hospital Guidelines
Toxicology Information
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Online Store
About Us
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Conflict of Interest Policy & Form
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Conflict of Interest Policy & Form
AACT Conflict of Interest Disclosure Form
Name
First
Last
Position at AACT
Consent
*
I have read AACT’s Conflict of Interest policy approved by the Board of Trustees on 10/05/2006 and understand that it is my obligation to act in a manner that promotes the best interests of AACT and to avoid conflicts of interest when making decisions and taking actions on behalf of the AACT.
My answers to this disclosure form are correctly stated to the best of my knowledge and belief. Should a possible conflict of interest arise in my responsibilities to AACT, I recognize that I have the obligation to notify, based on my position, the appropriate individual (President, Treasurer) and to abstain from any participation in the matter until AACT can determine whether a conflict exists and how that conflict shall be resolved. If any relevant changes occur in my affiliations, duties, or financial circumstances, I recognize that I have a continuing obligation to file an amended “Conflict of Interest Disclosure Form” with the AACT office.
I understand that the information on this form is solely for use by AACT and is considered confidential information. Release of this information within AACT will be on a need-to-know basis only. Release to external parties will be only when required by law and/or federal regulations.
I have read the AACT policy entitled “Conflict Of Interest” and I agree to comply with its terms.
*
1. Are you or a member of your immediate family an officer, director, trustee, partner (general or limited), employee or regularly retained consultant of any company, firm or organization that presently has business dealings with AACT or which might reasonably be expected to have business dealings with AACT in the coming year?
*
Yes
No
If yes, please list the name of the company, firm or organization, the position held, and the nature of the business which is currently being conducted with AACT or which may reasonably be expected to be conducted with AACT in the coming year:
2. Do you or does any member of your immediate family have a financial interest, direct or indirect, in a company, firm or organization that currently have business dealings with AACT or which may reasonably be expected to have such business dealings with AACT in the coming year?
*
Yes
No
If yes, please list the name of the company, firm or organization, the nature of the interest and the name of the person holding the interest, and the nature of the business which is currently being conducted or which may reasonably be expected to be conducted with AACT in the coming year:
3. Do you or does any member of your immediate family have a financial or personal interest in an entity in which AACT has a financial or other vested interest.
*
Yes
No
If yes, please provide details below:
4. Have you or an immediate family member accepted gifts, gratuities, lodging, dining, or entertainment that might reasonably appear to influence your judgment or actions concerning the business of AACT?
*
Yes
No
If yes, please provide details below:
5. Do you have any other interest or role in a firm or organization, where that interest or relationship might reasonably be expected to create an impression or suspicion among the public or AACT members having knowledge of your acts that you engaged in conduct in violation of your trust as a trustee or officer of AACT?
*
Yes
No
If yes, please provide details below:
Please upload additional documents as needed.
If any material changes to the responses provided on the annual disclosure form occur before the next form is due, the trustee, officer or employee is required to update the information on this form, and submit the update to the Secretary.
Max. file size: 128 MB.
Signature
Signature
Date
MM slash DD slash YYYY
Δ
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