Technical Expert Panel Nomination Disclosure Agreement Form (Page 2 of 2) in pdf

Technical Expert Panel Nomination Disclosure Agreement Form Page 2

Technical Expert Panel

Applicant/nominee’s disclosure

1. Do you or any family members have a financial interest, arrangement or affiliation with any corporate

organizations that may create a potential conflict of interest? Yes

/ No .

If yes, please describe (grant/research support, consultant, speaker’s bureau, major stock shareholder, other

financial or material support). Please include the name of the corporation/organization.

2. Do you or any family members have intellectual interest in a study or other research related to the quality

measures under consideration? Yes

/ No .

If yes, please describe the type of intellectual interest and the name of the organization/group.

Applicant/nominee’s agreement

If at any time during my service as a member of this TEP, my conflict of interest status changes, I will notify CORE.

CORE anticipates there will be two 1-2 hour teleconference meetings between July 2013 and December 2013. I am

able to commit to attending at least 90 percent of all TEP meetings (face-to-face or by telephone).

If selected to participate in the TEP and the measures are submitted to a measure endorsement organization (e.g.,

National Quality Forum [NQF], AQA Alliance) for approval, I will be available to discuss the measures with the

organization or its representatives, and work with the measure contractor to make revisions to the measures if

necessary.

If selected to participate in the TEP, I will keep confidential all materials and discussions until CMS authorizes their

release.

I have read the above and agree to abide by it.

Signature: __________________________________________ Date: _______________________

A Blueprint for the CMS Measures Management System, Version 9

Health Services Advisory Group, Inc.

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Technical Expert Panel Nomination Disclosure Agreement Form Page 2