North Carolina Occupational Therapy Association, Inc

The Florida Occupational Therapy Association

Conflict of Interest Agreement

The standard of conduct at the Florida Occupational Therapy Association, Inc. (FOTA) is that all elected and appointed leaders scrupulously avoid any conflict of interest between the interests of the FOTA on one hand, and personal, professional, and business interests on the other. This includes avoiding actual conflicts of interest as well as perceptions of conflicts of interest.

I understand that the purposes of this policy are: to protect the integrity of FOTA’s decision-making process, to enable our members and the public to have confidence in our integrity, and to protect the integrity and reputation of our leadership.

Upon or before taking office or assuming a leadership position, I will make a full, written disclosure of interests, relationships, and holdings that could potentially result in a conflict of interest. This written disclosure will be kept on file and I will update the disclosure as appropriate, and at least annually.

In the course of meetings or activities, I will disclose any interests in a transaction or decision where I (including my business or any other profit or non-profit affiliation), my family and/or my significant other, employer, or close associates will receive a benefit or gain. After disclosure, I understand that the other board members present will determine whether I may remain present or may participate in discussion. If I remain present for discussion, I understand that I will be asked to leave the room and will not be permitted to vote on the question.

I understand that this policy is meant to be a supplement to good judgment, and I will respect its spirit as well as its wording.

Signature: Position:

Printed name: Date:

The Florida Occupational Therapy Association

Disclosure of Interests, Relationships and Holdings

Employment:

I and my immediate family members are employed by or provide contractual professional services to the following entities:

Ownership:

I or my immediate family member is an owner, partner or shareholder in the following entities which may provide or purchase goods or services from FOTA, provide or purchase goods and services to FOTA, any entity which may provide occupational therapy services or employ occupational therapy personnel, and any entity which is involved in payment or regulation of occupational therapy practice.

Other interests:

I am involved in the leadership or I volunteer for the following “for profit” and “not-for-profit organizations”:

SignatureInitial completion date:

Printed name:Position:

Reviewed and amended:

Signature:Date:

Effective: 5/26/09