ISGD Conflict of Interest Disclosure Statement

  • ISGD Conflict of Interest Policy Acknowledgment and Disclosure Statement

    The purpose of this form is to disclose any actual or potential conflicts of interest, as defined in the International Society of Glomerular Disease's Conflict of Interest Policy. The information you provide will be used by ISGD's Board of Directors and staff in order to fulfill ISGD's compliance obligations and ensure we are conducting our activities according to the highest ethical standards and applicable regulations.

  • Please provide full and accurate information so that we can work with you to manage any potential conflicts of interest appropriately. Please also disclose any situation that could appear to be a conflict of interest, even if you believe it is not a true conflict of interest. Many potential conflicts can be managed, as long as they are disclosed appropriately.

    If the Board has any questions or needs additional information, they will contact you to discuss further. Thank you!

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  • I am (select all that apply):*

  • Conflict of Interest Policy

  • The policy is also available to read on our website: https://www.is-gd.org/conflict-interest-policy

  • This Conflict-of-Interest Disclosure Statement has been prepared to carry out the policy and procedures set forth in the Conflict-of-Interest Policy (the "Policy") of the International Society of Glomerular Disease (“ISGD”).  All terms used below are as defined in the Policy.


    I, {name}, acknowledge that, in carrying out my duties for ISGD and/or ISGD’s Board or Pillar Committees, I am charged with a duty of fiduciary trust with respect to ISGD and/or am being asked to comply with the Provisions of the ISGD Conflict-of-Interest Policy. I acknowledge my responsibility to act in the course of my duties solely in the best interests of ISGD, without considering my interests or the interests of any other person or entity, and to refrain from taking part in any transaction or other activity if I do not believe in good faith I can act with undivided loyalty to ISGD.

    I agree to comply with all the terms of the Policy, including the Standards of Conduct, and in furtherance of this compliance, I have listed below all interests and activities in which I or a member of my Family is engaged, which may constitute a Controlling Interest, Financial Interest, Ownership Interest, and/or Significant Relationship under the Policy. If neither I nor a member of my Family has a Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship to be listed, I have indicated this by selecting "none". This list is presented for disclosure to and evaluation by ISGD.

  • Disclosures

    For definitions of terms, please refer to Article III of the Conflict of Interest Policy.

  • Controlling Interest

    Do you have, or have you had within the past two years:
  • a CONTROLLING INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*
  • a CONTROLLING INTEREST in any organization that is seeking to do business with ISGD?*
  • a CONTROLLING INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

  • Financial Interest

    Do you have, or have you had within the past two years:
  • a FINANCIAL INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*
  • a FINANCIAL INTEREST in any organization that is seeking to do business with ISGD?*
  • a FINANCIAL INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

  • Ownership Interest

    Do you have, or have you had within the past two years:
  • an OWNERSHIP INTEREST in any organization that does business with ISGD (for example: corporate partners or sponsors, vendors)?*
  • an OWNERSHIP INTEREST in any organization that is seeking to do business with ISGD?*
  • an OWNERSHIP INTEREST in any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

  • Significant Relationships

    Do you have, or have you had within the past two years:
  • a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any organization that does business with ISGD (for example: corporate partners or sponsors, allied nonprofits, vendors, grant recipients)?*
  • a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any organization that is seeking to do business with ISGD?*
  • a SIGNIFICANT RELATIONSHIP (including a contractual compensation relationship) with any other pharmaceutical company, kidney healthcare company, or nephrology organization?*

  • Discounts, Rebates, and Reduced Prices

    Note: Please answer with reference to the past two years, as well as your current situation.

  • Acknowledgement and Certification

    Please read and sign.

  • Except as disclosed in this Disclosure Statement, I hereby certify that neither I nor any member of my Family has a Controlling Interest, Financial Interest, or Ownership Interest in, or Significant Relationship with, or receives services or products at reduced prices, discounts, or subject to rebates from an Organization which may, or which may appear to, conflict with the interests of ISGD. I further certify that, except as disclosed in this Disclosure Statement, I am not an officer, director, trustee, or employee of an Organization.

    If a Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship arises after my submission of this Disclosure Statement, I agree to disclose the existence and nature of such Controlling Interest, Financial Interest, Ownership Interest, or Significant Relationship to the Board as soon as reasonably practicable. I hereby assume the duty of notifying ISGD’s Secretary, in writing or as otherwise specified by the Board of Directors, of any additions to, deletions from, or modifications to the information I have provided in this Disclosure Statement.

    I acknowledge that I have received a copy of the Policy, that I have read and understand the Policy, and that I agree to comply with the Policy. I understand that ISGD is a tax-exempt organization and that, in order to maintain its federal tax-exemption, it must engage primarily in activities which accomplish one (1) or more of its tax-exempt purposes.

    I hereby certify that all of the information I have supplied in this Disclosure Statement is true and correct to the best of my knowledge, information, and belief.

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