Updated April 15, 2010

Using this Conflict of Interest Complaint Form

» Download the Heart Rhythm Society Conflict of
Interest Complaint Form (Microsoft Word, 54K)

To the Complainant:

The Heart Rhythm Society and the Heart Rhythm Foundation are committed to upholding the highest ethical values and to encourage professional and principled behavior by its staff and volunteers. The Society has an Ethics Oversight Committee which has established procedures for monitoring disclosures and ensuring compliance with the Heart Rhythm Society’s Code of Ethics and Professional Standards. It is the role of the Society and the Foundation to educate officers, trustees, volunteers, staff and other members on these issues, actively recognize potential problems and develop proactive policies for individuals and the organization. Each Society and Foundation trustee, officer, chair, committee, task force and writing group member, and staff member receives a copy of the Society’s Code, and conflict of interest disclosure statements are filed annually by volunteers and senior staff.

Allegations of conflict of interest are taken seriously and are investigated by the Society's Ethics Oversight Committee or, in the case of allegations of bias in educational activities, by the Education and/or Scientific Sessions Program Committee.

Please download the form or print this page, provide all requested information, sign and date the form, and return it to: Heart Rhythm Society | 1400 K Street N.W., Suite 500 | Washington, D.C. 20005. Your complaint will be referred to the appropriate committee, and you will be informed in writing of the outcome of its review and decision.

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Conflict of Interest Complaint Form

The complaint described below:

 

 

□ Occurred during an educational activity sponsored by the Heart Rhythm Society.

• Name of activity:
• Date of activity:

  — OR —

□ Is a general allegation not connected to a Society- or Foundation-sponsored educational activity.

Please state the nature of your complaint and include any background information or evidence you wish to be considered by the investigating committee. Use additional space if needed.

 

 

 

 

 

 

 

Signature (required): ________________________________________________

 

Date: ______________________

 

Printed Name: ______________________________________________________