SOCIETY FOR LABORATORY AUTOMATION AND SCREENING DIRECTOR, OFFICER, AND COMMITTEE MEMBER ANNUAL DISCLOSURE STATEMENT

Transcription

1 The purpose of this form is to ensure governance transparency; to openly identify any personal or business interests that may compete with SLAS interests. Having and identifying potentially competing interests does not disqualify you from serving as a volunteer. Making them known openly is, however, an important part of our bylaws and standard operating procedure. In the event that a discussion or decision would ever involve a potential conflict of interest, you simply would recuse yourself from the discussion and from voting. Please sign this form and return it to Suanne Determan (sdeterman@slas.org). In the meantime, if you have any questions or concerns, please let Suanne know. Thank you. SOCIETY FOR LABORATORY AUTOMATION AND SCREENING DIRECTOR, OFFICER, AND COMMITTEE MEMBER ANNUAL DISCLOSURE STATEMENT In an effort to identify potential conflicts of interest, the Society for Laboratory Automation and Screening ( SLAS ) Conflict of Interest Policy requires the directors, officers, and committee members of the SLAS to annually disclose interests that could give rise to a conflict by completing this Annual Conflict of Interest Disclosure Statement ( Statement ). For purposes of this Statement, the term affiliated person(s) means: your spouse, domestic partner, parents, grandparents, great-grandparents, brothers and sisters (whether whole or half-blood), children (whether natural or adopted), grandchildren, great-grandchildren, and spouses of an individual s brothers, sisters, children, grandchildren, and great-grandchildren; any corporation, limited liability company, partnership, or other organization of any kind of which you are a director, an officer, a partner, or participate in management or are employed by, or are, directly or indirectly, a debt holder or the beneficial owner of any class of equity securities; and any trust or other estate in which you have a substantial beneficial interest or as to which you serve as a director or in a similar capacity. SLAS GLOBAL HEADQUARTERS SLAS EUROPE OFFICE 100 Illinois Street, Suite 242 Boulevard du Souverain, 280 St. Charles, IL USA B-1160 Brussels, Belgium P: Tel: US Toll Free: SLAS (7527) europe@slas.org slas@slas.org

2 1. Please provide the following information about yourself: Full Name: Home Address: Home Telephone: Business Telephone: Address: 2. Please identify your role with SLAS: Board of Directors ( Board ) Officer (specify your position): Committee member (specify the committee or committees): 3. Please describe your current principal occupation including the name and address of your business and/or employer: 4. Have you or any of your affiliated persons received compensation from SLAS as an employee or independent contractor during the preceding eighteen (18) months? If yes, please describe in detail the circumstances under which compensation was paid by the SLAS, the compensation amount, and if the person compensated was an affiliated person, please identify the affiliated person and your relationship with that person:

3 5. Do you anticipate you or any of your affiliated persons receiving compensation from the SLAS as an employee or independent contractor during the next eighteen (18) months? If yes, please describe in detail the circumstances under which you anticipate compensation being paid by the SLAS, the anticipated amount of compensation, and if the person compensated will be an affiliated person, please identify the affiliated person and your relationship with that person: 6. Were you or any of your affiliated persons a party (lender or borrower) to a loan with the SLAS which was outstanding during the preceding eighteen (18) months? If yes, please describe in detail the terms of the loan, the amount of the loan, and if the loan involved an affiliated person, please identify the affiliated person and your relationship with that person: 7. Did you or any of your affiliated persons receive a grant, scholarship, fellowship, internship, prize, award, assistance, or other benefit of any kind (including goods, services, or use of facilities) (collectively, Grant ) from SLAS during the preceding eighteen (18) months? If yes, please describe the Grant in detail, the value of the Grant, and if the Grant involved an affiliated person, please identify the affiliated person and your relationship with that person: 8. Were you or any affiliated person directly or indirectly a party to a business transaction involving the SLAS during the preceding eighteen (18) months? The payment of SLAS membership dues is not considered a business transaction for purposes of this question.

4 If yes, please describe each business transaction in detail, the value of the business transaction, and if the business transaction involved an affiliated person, please identify the affiliated person and your relationship with that person: 9. Do you anticipate that you or any of your affiliated persons will be directly or indirectly a party to a business transaction involving the SLAS during the next eighteen (18) months? The payment of SLAS membership dues is not considered a business transaction for purposes of this question. If yes, please describe each business transaction in detail, the value of the business transaction, and if the business transaction will involve an affiliated person, please identify the affiliated person and your relationship with that person: 10. Do you or any of your affiliated persons have a family or business relationship of any kind with any SLAS director, officer, committee member, or employee? If yes, please identify the SLAS director(s), officer(s), committee member(s), and employee(s) with whom you have the family or business relationship and describe the family or business relationship: 11. Do you or any of your affiliated persons have any interest in any business or organization which furnished in the past eighteen (18) months, is currently furnishing, or may seek to furnish in the future, goods or services to the SLAS? If yes, please describe the nature of the goods or services, the business or organization, and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

5 12. Are you or any affiliated person currently asserting, or do you or any affiliated person intend to assert in the future a claim, cause of action, or grievance of any kind or nature against the SLAS? If yes, please provide the following information with respect to the claim, cause of action, or grievance: (i) the nature of the claim, cause of action, or grievance; (ii) the basis of the claim, cause of action, or grievance; (iii) the parties involved in the claim, cause of action, or grievance; and (iv) the present status of the claim, cause of action, or grievance. In addition, if the claim, cause of action or grievance involves an affiliated person, please identify the affiliated person and their relationship to you: 13. Are you aware of any other events, transactions, arrangements, or other situations that you believe may give rise to a conflict of interest, the appearance of a conflict of interest, or which you otherwise believe should be examined by the Board to determine if a conflict of interest exists? If yes, please describe in detail the situation(s): 14. Are you aware of any relationship, interest, or other situation involving yourself or your affiliated persons that would or may prevent you from fulfilling your fiduciary duties of care and loyalty to the SLAS? If yes, please describe in detail the relationship, interest, or situation: I HEREBY CONFIRM that I have read and understand SLAS s Disclosure Policy and that my responses to the above questions are complete and correct to the best of my knowledge and belief.

6 Signature Date