AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY
VOLUNTEER APPLICATION
Please return all documents by September 30, 2014
to jdimisa@asnc.org
Yes, I want to volunteer for ASNC.
Please provide a brief response to the following questions and complete as much of the application as possible. You
may attach additional sheets. Please provide a current CV and complete the attached BioSketch and Disclosure
statement. You may also include letters of recommendation, if you like.
Why do you want to participate on an ASNC Committee?
What expertise do you bring to ASNC?
Please mark 1 or 2 next to your first and second choices for committee participation. There are a limited number of
slots on each committee. Thank you.
___
___
Annual Program
Membership
____
____
Education
____ Health Policy
Quality ____ Technology
Other areas or topics in which you would be interested in volunteering:
NAME:
TITLE:
ORGANIZATION:
ADDRESS:
TELEPHONE: (Note whether it is office or mobile.)
FAX:
EMAIL:
TWITTER:
CITY, STATE, ZIP
____ International
BIOSKETCH
NAME:
PHONE NUMBER (used by staff to contact you for notification of selection status):
PRESENT POSITION:
EDUCATION (include residency & fellowship training site; dates included):
PLEASE BRIEFLY LIST THE FOLLOWING: (PLEASE KEEP TO 2 PAGES)
1.
PROFESSIONAL EXPERIENCE AND ACADEMIC APPOINTMENTS
2.
ASNC PARTICIPATION TO DATE
3.
ASNC PARTICIPATION NOT INCLUDED ON AN ASNC COMMITTEE INVOLVEMENT LISTING
4.
PARTICIPATION IN PROFESSIONAL SOCIETIES AND NATIONAL ORGANIZATIONS
5.
ACTIVITIES ON BEHALF OF CARDIOVASCULAR IMAGING/PRACTICE
6.
HONORS AND AWARDS
Conflicts of Interest/Relationships with Industry Notice
Complete and return the following form.
The American Society of Nuclear Cardiology is committed to ensuring balance, independence, objectivity, and scientific
rigor in its governance and activities. Members participating on Society committees and other activities are expected to
disclose all relevant financial and other relationships during the past 12 months related to the content of the Society
activity that could actually or potentially reasonably be viewed to bias or pre-dispose the member in his/her decisionmaking and work on behalf of the Society.
Therefore:

Members will strive to identify and resolve actual and potential conflicts of interests in his or her professional
practice and service to the Society.

Members will proactively review and be familiar with the Society’s Conflicts of Interest/Relationship with
Industry Disclosure Form and the different forms that actual and potential conflicts may take, e.g., financial,
personal, institutional, professional, etc.

Members must disclose all such potential and actual conflicts and relationships. Examples of such conflicts
potentially include:
o Honoraria and/or consulting fees
o Ongoing Officer, Board, or other governance service with other related medical or cardiovascular
organizations.

Members should be prepared to address an actual or potential conflict as directed by the Society leadership or
Chair as a condition of committee or other Society service. If a conflict cannot be adequately resolved consistent
with the foregoing, then the member will withdraw from the relationship or service to the Society.

Members will be aware of institutional conflicts of interest, as well as other professional relationships, in their
relations with and service to the Society.
AMERICAN SOCIETY OF NUCLEAR CARDIOLOGY
Annual Disclosure and Attestation Form
The intent of this disclosure is to allow the American Society of Nuclear Cardiology (ASNC) the opportunity to obtain
relevant financial relationships from all persons that will influence the content of ASNC certified activities. This
information will be used to identify and resolve any potential conflicts of interest to assure balance, independence,
objectivity and scientific rigor in all of its educational activities as well as committee activities. All planners,
directors/editors, faculty, authors and peer reviewers of ASNC-sponsored educational activities as well as all relevant
committee members and staff are expected to disclose to ASNC any relevant financial relationships with any
commercial interest that produces health care goods or services consumed by or used on patients, including computer
software/hardware, related to the content of the educational presentation or committee activity.
Definitions:
 Commercial interest: Any entity producing, marketing, reselling, or distributing health care goods or services
consumed by, or used on, patients.
 Conflict of interest:. ASNC considers financial relationships to create actual conflicts of interest when
individuals have both a financial relationship with a commercial interest and the opportunity to affect the
content of an educational activity about the products or services of that commercial interest.
 Financial relationships: Those relationships in which the individual benefits by receiving a salary, royalty,
intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other
ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually
associated with roles such as employment, management position, independent contractor (including
contracted research), consulting, speaking and teaching, membership on advisory committees or review panels,
board membership, and other activities for which remuneration is received or expected. Relevant financial
relationships would include those within the past 12 months of the person involved in the activity and his/her
spouse or partner. Relevant financial relationships of a person’s spouse or partner are those of which the
person is aware at the time of this disclosure.
__________________________________________________________________________________________________
__________________________________________________________________________________
PLEASE COMPLETE BOTH PAGES AND SIGN ON THE SIGNATURE LINE ON PAGE 2.
I._Disclosure:
Name of Planner, Faculty, Author, Reviewer, Committee Member or Relevant Staff:
Do you or your spouse/partner have relevant financial relationships (past 12 months) with commercial interests
producing health care goods or services consumed by/used on patients, including computer software/hardware?
 Yes  No
If yes, please identify the commercial interest next to the best description of this relationship and answer the 3
questions below.
Description of Financial Relationship
Name of Commercial Interest – Please print/provide a typed list
Royalty
____________________________________________________________________
Intellectual property rights
____________________________________________________________________
Consulting Fee
____________________________________________________________________
Honoraria
____________________________________________________________________
Research Grant/Research
____________________________________________________________________
Speakers’ Bureau
____________________________________________________________________
Advisory Board
____________________________________________________________________
* Salary
____________________________________________________________________
*Ownership Interest (e.g. stocks,
stock options or other ownership
interest, excluding diversified
mutual funds:
____________________________________________________________________
Other financial benefit (please
specify)____________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________
*Please note ACCME policy: Employees or owners of commercial interests may serve as planners or speakers/authors
in CME activities only if the content that he/she controls DOES NOT relate to the business lines and products of the
employer. If the CME content that the employee/owner controls, relates to the company business
lines/products/services it is an unresolvable conflict and he/she may not serve as a contributor to this activity.
Please note that this form applies to all CME activities you may perform with the ASNC over the next 12 monthsplease complete all five (5) sections and advise ASNC if changes occur over the next 12 months.
II. Attestation Statements (all contributors):
As a content contributor for one of ASNC’s educational activities, we request that you attest to the following statements.
Please read each statement and place a check in the box below to indicate your understanding of and willingness to
comply with these statements.

I will support my presentation and/or clinical recommendations with the “best available evidence” from the
medical literature. Any recommendations involving clinical medicine will be based on evidence that is accepted
within the profession of medicine as adequate justification for their indications and contraindications in the care
of patients.

I agree that all scientific research I refer to, report or use in support or justification of patient care
recommendations will conform to the generally accepted standards of experimental design, data collection and
analysis.

I agree to disclose when discussion of an off-label use of a product or an investigational use not yet approved
occurs during the course of my presentation.

My presentation will not promote the products or services of any commercial interest and will give a balanced
view of therapeutic options. I will not use trade names for healthcare products or services.

I will not accept any honorarium/payment/reimbursement beyond what has been agreed upon directly with
ASNC.

If any portion of my presentation, such as slides, is not original work, I will obtain necessary copyright
permissions.

My presentation is HIPAA compliant (e.g. I have only used de-identified patient information).

I will submit my talk in advance to allow for adequate peer review. I agree to submit my final presentation in its
final form at least one month prior to the first date of the meeting at which I am presenting.
I agree to comply with the attestation statements above:  Yes
 No
III. Planner’s Attestation Statements (planners, directors, editors): In the event that you are involved in planning an
ASNC Educational Activity, please complete the following:


I will ensure that any speaker, content or activity recommendations I suggest are independent of commercial
bias. I will support my clinical recommendations with the “best available evidence” from medical literature and
ensure valid content.
 Yes  No
I agree to recuse myself from planning activity content in which I have a conflict of interest.
 Yes  No
IV. Peer Reviewer Attestation: In the event that you are invited to peer review content for a CME activity:
 I agree to recuse myself from peer reviewing content related to the products or services produced by the
commercial interest with which I have a financial relationship.
 Yes  No
V. Conflict Resolution (see Definitions section for ACCME definition of “conflicts of interest”):
To assure balance, independence, objectivity and scientific rigor in all certified activities, ASNC is required by ACCME to
resolve conflicts of interest created by financial relationships with a commercial interest. Standard resolution
mechanisms will apply to this activity including recusal (planners & reviewers) and advance peer review of content
(presenters). We will notify you under separate cover of any additional mechanisms identified for this activity, or if a
conflict was deemed unresolvable.
To assist ASNC in its responsibility to ensure appropriate choice of those that will affect CME content, please check
whether one or more of the following already applies toward your participation:
1. I will or have already divested myself of this financial relationship.
 Yes  No
2. I will limit my control over the CME content. I will refrain from making recommendations, regarding products or
services with which I have a financial relationship, e.g. limit presentations to pathophysiology, diagnosis, and/or
research findings.
 Yes  No  Not Applicable
3. I plan to discuss off-label usages as part of my presentation(s); I will agree to ASNC’s requirement to disclose the offlabel usage to learners.
 Yes  No  Not Applicable
4. I will recommend an alternate planner/presenter//reviewer for this activity, who has no relationships with industry,
for the ASNC planning committee’s consideration.
 Yes  No  Not Applicable. If yes, who do you recommend?
_________________________________
Signature:
Date:
Important Note: Due to ACCME requirements, failure to disclose relevant financial relationships, or failure to
agree to ASNC attestation statements will automatically disqualify one from planning, presenting or reviewing a
certified activity.