Employee Conflict of Interest Disclosure – Emergency Medical Services University, LLC

Name:

Position

Please answer the following questions. Present them to your students upon the commencement of any presentation.

1.) Disclose any financial relationship you have with organizations other than the CE provider. Include a brief description of the nature and purpose of the organization(s).

2.) Disclose your position of employment. Includie the nature of your employers business, the position you hold and a description of your daily employment responsibilities.

3.) Disclose any outside relationships that you hold with any person or entity from which the CE provider obtains substantial amounts of goods and services. Or which provides services that substantially compete with the CE provider where the relationship involves: a. Holding a position of responsibility. b. A substantial financial interest (other than owning less than 1% interest in a publicly traded company) c. The receipt of any unusual gifts or favors.

Choose between a. b. or c.

4.) Disclose any financial interests or positions of responsibility in entities providing goods or services in support of EMS practice, other than owning less than a 1% interest in a publicly traded company.

5.) Disclose any other interest that may create a conflict of interest, or the appearance of a conflict of interest with CAPCE or with the CE provider.

Date

any or traded

Signature

Clear Signature

I hereby attest to the above information regarding any conflicts of interest. In the event that circumstances change, I agree to fill out and provide administration with a new form.

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