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Verification of eligibility
Only those individuals who have no current ties to industry and who have received no remuneration from industry in the past two years are eligible to be appointed to OMeGA’s Review Committee. OMeGA Review Committee members and their immediate family members must meet the following requirements:
I verify that I/we have no “financial interest” in any orthopaedic medical device, pharmaceutical and biotechnology companies. “Financial interest” shall mean ownership or personal compensation arrangements such as employment, consulting, speaking, or development relationships. Ownership of less than 5% in publicly traded securities and mutual funds in an orthopaedic medical device, pharmaceutical and biotechnology companies will not be considered a “financial interest.”
I will disclose all leadership roles in orthopaedic fellowship or residency programs and educational institutions that may apply for a grant, recusing myself from consideration of grant applications made by institutions with which I have been associated, currently or in the last two years. “Leadership role” is defined to include a department chair or other position that involves financial decision making within the orthopaedic department of an institution, currently or in the previous two years.
I have not participated in reportable payment activities detailed in the Centers for Medicare & Medicaid Services (CMS) Fact Sheet for Physician Open Payments.
I will disclose any other financial or other personal considerations that may compromise, or mayhave the appearance of compromising, my ability to serve as an objective evaluator of graduate medical education programs.These current considerations include (if any):
Emerging Leaders must answer these two additional questions:
Yes No (Select one.)I have been a member of the Emerging Leaders Program (ELP) for five years or more.
Ifyes, what year did you join ELP?
Yes No (Select one.)I have been in practice for a minimum of five years or more.
Return this form along with your CV and any additional disclosuresbyFriday, November 3, 2017,to:
OMeGA Medical Grants Association,email:.