Pursuant to the purposes and intent of the resolution adopted by the Board of Directors of the Utah Society for Respiratory Care, requiring disclosure of certain interests, a copy of which has been furnished to me, I hereby state that I or members of my immediate family have the following affiliations or interests or have taken part in the following transactions that, when considered in conjunction with my position with, or relation to, the Society, might possibly constitute a conflict of interest. (Check "none" where applicable.)
Outside Interests: Identify any purchases or sales or property or property rights, interests, or services by yourself or your immediate family that might be deemed to have been in competition with the Society.
Outside Activities: Identify any instances in which you or any member of your immediate family have rendered directive, managerial or consultant services to any outside concern that does business with, or competes with, the services of the Society or have rendered any other services in competition with the Society.
Gifts, Gratuities, and Entertainment: Neither I nor any member of my immediate family have accepted gifts, gratuities, or entertainment from any outside concern that does, or is seeking to do, business with, or is a competitor of the Society except as listed below:
Inside Information: Neither I nor any member of my immediate family have disclosed or used information relating to the Society's business for the personal profit or advantage of myself or my immediate family, except as listed below:
Other: List any other activities in which you or your immediate family are engaged in what might be regarded as constituting a conflict of interest.
I hereby agree to report to the USRC President, any further transactions that may develop before the completion of my next questionnaire.
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