Society of Nuclear Medicine Technologist Section s1

Candidate Application Form 2015-2016

TO: SNMMI-TS Membership

FROM: SNMMI-TS Nominating Committee Chair, D. Scott Holbrook, BS, CNMT, FSNMMI-TS

DATE: November 1, 2014

RE: First Call for Nominations for SNMMI-TS Elections for 2015-2016

This notice will serve as the official Call for Nominations for the 2015-2016 SNMMI-TS National Election. We encourage anyone who is interested to contact D. Scott Holbrook, BS, CNMT, FSNMMI-TS, Chair of the SNMMI-TS Nominating Committee, c/o Nikki Wenzel-Lamb at nwenzel- [email protected] to secure your place on the ballot.

We also urge you to contact your chapter leadership now so that you may secure nominations prior to the deadline. It is important that each Chapter provide names of qualified candidates to serve in this opportunity for chapter representation the national level, allowing your Chapter to have direct input into the activities of the SNMMI-TS.

The deadline is December 1, 2014 for receipt of the Curriculum Vitae and all required items of each nominee.

There are 4 positions for the 2015-2016 ballot:

President-Elect 2 year term (2nd year President) Secretary 1 year term Tech Delegate-at-Large 3 year term (1 position open) (representative to HOD) Finance Committee Member 3 year term

1 CONTACT INFORMATION

Name Professional Title Chapter SNM Membership #

Preferred Mailing Address Institution/Company/Attn Street Apartment/Suite City State Zip Code

Phone and email (please give all numbers at which SNM staff may contact you if necessary) Preferred? Home phone number Cell phone number Work phone number Fax number Email address Alternative email address

Assistant/Office contacts Name Address if different from above Work phone number Fax number Email address

2 OFFICES The Nominee is prepared to stand for the position of:

 President-Elect

Qualifications: Experience as an Officer or Committee Chair at the National Level

Time commitment: 3 years (President-Elect, President, and Immediate Past President)

Letters of Support: Chapter or SNMMI-TS Leadership AND Employer (Attachment A & B)

 Secretary

Qualifications: Experience as a National Council Delegate or Committee Chair at the National Level.

Time commitment: 1 year

 Finance Committee Member

Qualifications: Experience in an elected or appointed position at the National Level or as Chapter President. Financial experience preferred.

Time commitment: 3 years (2 years as a committee member and final year as Finance Chair)

 Delegate-at-large

Qualifications: Experience as a national/chapter officer, Committee/Task Force Chair or National Council of Representatives at the National Level

Time commitment: 3 years

 Member-at-large

 Qualifications – For two (2) positions nominated from the membership - Must be active in the SNMMI-TS for the last three consecutive years. If elected, must not hold concurrent National Council of Representative position during term of office. Past Presidents are not eligible to serve in this capacity for two years following the completion of their term as Immediate Past President..

Time commitment: 2 years

 Specialty Area Representatives (Manager and Industry)

 Qualifications – Must be active in the SNMMI-TS for at least three (3) consecutive years. Must be presently working or hold a title in that specialty area. If elected must not hold concurrent National Council of Representative positions. Past Presidents are not eligible to serve in this capacity for two years following the completion of their term as Immediate Past President..

3 Time commitment: 2 years

4 SUPPORTING DOCUMENTS

The following is required from each nominee:

 Nominee’s Curriculum Vitae – please note, CV’s must be submitted in electronic format – faxed forms will NOT be accepted. (See attached template)  Education – indicate academic institution, years attended, degree(s) completed  Certification – indicate institution or program attended, years attended, credentials earned, and membership number  Offices held, including appointments – please list in chronological order, beginning with the most recent, offices held – please indicate office, term, and the sponsoring organization  Publications and Presentations – please note, the Election Bulletin will include only the number of publications and presentations, however, please provide complete references on your CV Presentations: Total # _____ Publications: Total # _____  Organizational Affiliations – other than the SNM or SNM  Awards and Recognition related to Nuclear Medicine  Leadership positions or training not included elsewhere

 Position Statement –  For President-Elect - a 250 word or less statement that addresses the following statement: Name 3 goals you would bring with you as President-Elect of the SNMMI-TS. (Attachment C)  For all other nominees – a 150 word or less statement that addresses the following question: How would you use your experience to be successful in this position? (Not applicable for Director-at-Large, Nominating Committee and Speaker-Elect of the National Council) (Attachment D)

 Letters of support – Each nominee must be endorsed by their Chapter leadership or a member of the SNMMI-TS Leadership - see the attached “Leadership Candidacy Support Form”. Further, the President-Elect must submit a letter of support from their employer – see attached “Employer Candidacy Support Form”

 Photograph – A recent high-resolution digital photograph (headshot).

Check here if you think your headshot may already be on file with SNM.

 Conflict of Interest Form – Use attached document.

The SNMMI-TS will not accept a nomination unless all of the above items are submitted.

5 Duties of the SNMMI-TS Officers

The Officers of the Section shall be President, President-Elect, Secretary, and Finance Chair.

Term of Office

The President, President-Elect, and Secretary shall serve a one-year term or until their successors are elected.

The Chairman of the Finance Committee shall serve for a one-year term.

The President-Elect shall automatically succeed to the office of the President at the conclusion of the President’s term.

Terms of office for the SNMMI-TS Officers will commence at the conclusion of the Annual Meeting of the Society.

Duties of Officers Officers shall have express authority and perform such duties in the management of the property and affairs of the SNMMI-TS as may be provided in the SNMMI-TS Bylaws, or as may be determined, from time to time, by the Executive Board. Officers shall have such implied authority as recognized by the common law and as prescribed in the Parliamentary Authority adopted by the SNMMI-TS.

6 Duties and Responsibilities of the SNMMI-TS President

SNMMI-TS Responsibilities: 1. Primary Spokesperson for the SNMMI-TS. 2. Presides over the Executive Board and any meetings of the membership. 3. Prepares Meeting Agendas for Executive Board and Annual Business Meetings. 4. Authorizes expenditures by the Finance Chair. 5. Provides timely communication to the general membership, the SNMMI-TS leadership, the SNM Leadership, and Imaging Community. 6. Works with SNM Communications staff to prepare articles for each issue of the Journal of Nuclear Medicine Technology and every second issue of UPTAKE, as well as an article for The Journal of Nuclear Medicine. 7. Performs other duties that usually pertain to the office of the President or as directed by the Executive Board. 8. Non-voting Member of the SNMMI-TS National Council of Representatives. 9. Ex-Officio (Non-voting) Member of all SNMMI-TS Committees, except the Nominating Committee. 10. Voting Member of the SNMMI-TS Finance Committee. 11. Voting Member of the SNMMI-TS Publications Committee. 12. Appoints all standing and special committee Chairs, committee and organizational liaison appointments. 13. Ensures that the committee Chairs understand the goals and objectives of their committees as designated in the SNMMI-TS Strategic Plan. 14. Delegates duties based off of the goals and objectives designated in the SNMMI-TS Strategic Plan. 15. Provides mentoring and guidance to the committee Chairs, Executive Board, and general leadership. 16. Acts as a conduit between the leadership and the SNM Staff, ensuring that projects are being worked on. 17. Ensures that the work of the SNMMI-TS is being accomplished. 18. The President may appoint an appropriate Parliamentarian to serve as his advisor and consultant on procedural matters.

The President (or his or her designee) shall serve as the official representative at outside meetings: 1. Liaison to the Alliance for Quality Medical Imaging and Radiation Therapy 2. Liaison to the ASRT Grassroots program RT in DC 3. Liaison to the Health Professions Network (HPN) 4. Liaison to the European Association of Nuclear Medicine (EANM) 5. Liaison to the American Healthcare Radiology Administrators (AHRA) 6. Liaison to the World Federation of Nuclear Medicine and Biology (WFNMB) 7. Presents the Annual Presidential Distinguished Service Award 8. Presents the Annual Fellow Presentations 9. Presents the Annual Meeting Awards 10. Presents Certificates of Appreciation

SNM Responsibilities 1. Voting Member of the SNMMI Executive Committee

7 2. Voting Member of the SNMMI Board of Directors 3. Non-voting Member of the SNMMI House of Delegates 4. Non-voting Member of the SNMMI-TS NCOR 5. Member of the SNM Committee on Chapters 6. Member of the SNM Committee on Councils and Centers 7. Member of the SNM Finance Committee

8 Duties and Responsibilities of the SNMMI-TS President-Elect

1. Acts for the President in the case of temporary absence 2. Serves as President’s designee in selected matters of the SNMMI-TS. 3. Should the office of President become vacant prior to the expiration of the current President’s term of office the President-Elect shall serve for the remainder of the President’s term as well as the term they were elected to serve as President. 4. Voting member of the Executive Board of the SNMMI-TS. 5. Non-voting member of the National Council of Representatives. 6. Voting member of the SNMMI-TS Finance Committee. 7. Chair of the Nuclear Medicine Week Task Force. 8. Voting member of the SNM House of Delegates. 9. Voting member of the SNM Board of Directors. 10. Member of the SNMMI-TS Bylaws Committee 11. Ex-Officio member of all SNMMI-TS committees and task forces. 12. Observes all the committees within the SNMMI-TS in order to devise planning and goals for their term of office. 13. Attends RSNA with the SNMMI-TS President. 14. Attends RT in DC. 15. Presents a gavel and plaque to the outgoing President at the SNMMI-TS Business meeting. 16. When the President-Elect of the Section assumes office at the time of the Annual Business Meeting, he or she will announce the Program Committee Chair that has been selected to serve during his or her term as President. 17. Works with SNM Communications staff to prepare an article for every second issue of UPTAKE and the Journal of Nuclear Medicine Technology (JNMT).

Required Meetings: 1. SNMMI Annual Meeting 2. SNMMI Mid-winter Meeting 3. SNMMI BOD Meetings 4. SNMMI-TS EB Meetings 5. SNMMI HOD Meetings 6. SNMMI-TS NCOR Meetings

9 Duties and Responsibilities of the SNMMI-TS Secretary

The office of the Secretary is an elected office and is elected annually by the membership by ballot.

The Secretary is responsible for certifying the minutes of the meetings of the SNMMI-TS and for the maintenance of the archives of the SNMMI-TS. This includes:

1. All National Council meetings. 2. All Executive Board Meetings. 3. All Technologist Section Business Meetings. 4. All other meetings that the President may call.

The Secretary is an executive officer and is a voting member of the Executive Board and a non- voting member of the National Council of Representatives.

The Secretary should be familiar with parliamentary procedures and know the bylaws and standing rules of the SNMMI-TS.

Specific Duties/Secretary:

Minutes: The minutes should be a recording of the business transacted, not what is said. The minutes should also include the following:

1. Type of Meeting (Executive Board, National Council of Representatives, Business meeting) 2. Name of Organization 3. Date and place of meeting 4. Names and offices of those present 5. Whether minutes of the last meeting were approved 6. All main motions carried or defeated 7. Points of order and appeals 8. Name and office or Chair of each individual giving a report 9. Time of adjournment

Corrections to the minutes are entered in the margin of the record book opposite the part to be corrected, giving the date of correction.

A copy of the completed minutes of the National Council of Representatives meeting is sent to the Central office for inclusion in the Agenda Book of the next National Council of Representatives Meeting.

A copy of the completed minutes will be sent to each of the Officers of the Executive Board.

Motions and Pertinent Business Items: Within two weeks following the National Council meeting, staff will send to the Central Office a list of motions made and pertinent business items from that meeting.

This will be distributed to all National Council of Representatives members, committee Chairmen, and staff directors.

Motion Forms:

10 A supply of printed motion forms will be given to the Secretary. These forms are available upon request at all meetings of the National Council of Representatives and Business meetings of the Section.

11 Duties and Responsibilities of the SNMMI-TS Finance Committee Chair

The office of Finance Committee Chair is elected by the membership by ballot. The individual, when elected, serves as a voting member of the SNMMI-TS Finance Committee for two years, prior to succeeding to the Chairmanship.

The Finance Committee Chair is a member of the Executive Board and Finance Committee and the Investment Subcommittee of the SNM and has voting privileges on the above.

Specific Duties/Finance Chair: 1. Advises the Finance Committee in the preparation of the budget. 2. Handles the monetary affairs of the SNMMI-TS. 3. Maintains proper accounts under the authorization and direction of the Executive Board. 4. Spends money as authorized by the President and the Executive Board. 5. Reviews and takes action on the monthly Statements of Activity. 6. Attends all Finance Committee, Executive Board, National Council of Representatives, and business meetings of the Section. 7. Submits written reports to the Executive Board, National Council of Representatives, and general membership at Section meetings. 8. Is responsible for the current Fiscal Year Budget. 9. Monitors expenditures and approves transfer of funds within the current budget. 10. Monitors expenditures of the SNMMI-TS President.

12 Other Elected Positions – Duties and Responsibilities

Duties and Responsibilities of the SNMMI-TS Delegate-at-Large (3-year time commitment) The SNMMI-TS Delegate(s)-at-Large serves as the SNMMI-TS Delegate for the SNM House of D elegates. They contribute to the management of business and financial affairs of the SNM. This individual will also serve as a voting member of the National Council of Representatives.

Duties and Responsibilities of the SNMMI-TS Member-at-Large (2-year time commitment) The SNMMI-TS Member(s)-at-Large serves as a representative of the SNMMI-TS general memb ership to the SNMMI-TS Executive Board. They contribute to the management of business and financial affairs of the SNMMI-TS.

Duties and Responsibilities of the SNMMI-TS Speaker of the NCOR (2-year time commitment)

1. Voting member of the Executive Board 2. Chairs meetings of the National Council of Representatives. 3. Establishes an agenda for the National Council of Representatives meeting to reflect action items and items for discussion by the NCOR to the beginning of the agenda. If some reports are not heard, they will be included in the written format. 4. Identifies hot topics for discussion and inclusion in the agenda of the National Council of Representatives. 5. Identifies issues important to delegates and Chapters for inclusion in the agenda. 6. Ex officio member of all NCOR committees, work groups, and task forces except the nominating committee. 7. Liaison between the National Council of Representatives, the Executive Board, and the Society. 8. Writes articles for UPTAKE and the Journal of Nuclear Medicine Technology as requested. 9. Clearly explains to all Specialty Representatives their roles and responsibilities and outlines how they can work to move forward with their responsibilities. 10. The Speaker of the NCOR, who is a member of the Executive Board, will submit a report to the NCOR following each Executive Board meeting with the outcome of any NCOR agenda items.

Outside of meetings: 1. Reports to the President on the activities of the National Council of Representatives prior to any meeting of the Executive Board. 2. Attends Chapter meetings as requested. 3. Creates task forces and workgroups within the National Council of Representatives to focus on issues specific to the National Council of Representatives with the approval of the Executive Board. 4. Communicates on a regular basis with members of the National Council of Representatives and the President of the SNMMI-TS and SNMMI-TS Administrator.

Duties and Responsibilities of the SNMMI-TS Specialty Area Representatives (2-year time commitment) The Specialty Area Representatives shall be elected by ballot by voting members of the NCOR. The names of nominees selected by the Nominating Committee shall be forwarded to the National Council of Representatives at least 60 days prior to the Annual Meeting of the Society. The nominee who receives the highest number of votes for any elected position shall be duly

13 elected. In the event of a tie vote, the National Council of Representatives members present at the Annual Meeting shall break the tie. The tabulation of ballots shall be performed by staff present at the meeting and certified by the Secretary of the Section. Results of the election shall be made known at the NCOR meeting at the Annual Meeting. Unless stated otherwise in the Bylaws, all rules and procedures for the conduct of nominations and elections shall be recommended by the Nominating Committee and approved by the Executive Board.

The following are the duties and responsibilities for these positions: 1. Attend and be prepared for all NCOR meetings (2 per year) 2. Read all material distributed to the NCOR 3. Review and request information on important matters requiring NCOR action 4. Engage in Committee, Task Force, and NCOR discussions and contribute fully to the analysis of proposals and presentations 5. Willingly serve on Committees and task forces that pertain to the interest of the represented specialty and/or industry

Additional responsibilities and duties of the specialty area representatives are listed below (by specialty area).

Manager Representative:

1. Identifies issues relevant specifically to management. 2. Works in conjunction with the Annual Program Committee to develop an educational offering with content specific to management. 3. Reports at least semi-annually, in conjunction with meetings of the Executive Board, on recent activities related to management. 4. Reports to the National Council of Representatives on management activities of like- minded organizations. 5. Writes articles for UPTAKE and Journal of Nuclear Medicine Technology as requested.

Industry Representative:

1. Identifies issues relevant specifically to nuclear medicine and molecular imaging industry. 2. Reports at least semi-annually, in conjunction with meetings of the Executive Board on recent activities related to nuclear medicine and molecular imaging industry. 3. Reports to the National Council of Representatives on nuclear medicine and molecular imaging industry activities of like minded organizations. 4. Writes articles for Uptake and JNMT as requested.

14 FINANCIAL OBLIGATIONS

Please initial below indicating your understanding of the financial obligations of election to office in the SNMMI-TS.

 The President-Elect and Secretary are expected to attend the Mid-Winter, Annual, and Fall meetings. An additional spring meeting may be added, as necessary. Travel expenses will be reimbursed for the Mid-Winter, Annual and Fall Board meetings - airfare, two nights hotel and actual expenses (meals not provided by SNMMI and travel to and from the airport) to attend the Mid-Winter and Annual Meeting.

 Members-at-Large of the SNMMI-TS Executive Board are expected to attend the Mid-Winter, Annual, and Fall meetings. An additional spring meeting may be added, as necessary. Travel expenses will be reimbursed for the Mid-Winter, Annual and Fall Board meetings - airfare, two nights hotel and actual expenses (meals not provided by SNMMI and travel to and from the airport) to attend the Mid-Winter and Annual Meeting.

 Speaker of the SNMMI-TS National Council is expected to attend the Mid-Winter, Annual, and Fall Executive Board meetings. An additional spring meeting may be added, as necessary. Travel expenses will be reimbursed for the Mid-Winter, Annual and Fall Board meetings - airfare, two nights hotel and actual expenses (meals not provided by SNMMI and travel to and from the airport) to attend the Mid-Winter and Annual Meeting.

 Members of the SNMMI-TS National Council of Representatives and SNMMI House of Delegates are expected to attend the Mid-Winter and Annual Meetings of each of those bodies.

o Tech Delegates-at-Large: SNMMI-TS Delegates-at-Large will be reimbursed for airfare, two nights hotel and actual expenses (meals not provided by SNMMI and travel to and from the airport) to attend the Mid-Winter and Annual Meeting.

(Please note: the NCOR Student Specialty Area Representative ONLY will receive reimbursement for airfare, two nights hotel and days actual expenses for the Mid-Winter and Annual Meeting.)

 The elected finance committee members are expected to attend the Mid-Winter, Annual, and fall finance committee meetings. Only the fall finance committee meeting expenses are reimbursed.

I have read, and understand the time commitment and financial reimbursement associated with the position I am seeking:

double click and type or print name double click and type member here number here

Name SNMMI member number

doube click and sign or insert electronic double click type or print date here signature here

Signature Date

16 Attachment A

Leadership Candidacy Support

I do hereby officially endorse type nominee name here as a candidate for the office of type position title within the SNMMI-TS. I am pleased to support this candidacy and affirm this candidates understanding of the duties and responsibilities of this office.

Typed or P r i n t e d

n a m e

Signature

17 Attachment B

Employer Letter of Support (For President-Elect, Secretary, and Finance Committee Positions only)

This letter is to acknowledge that type nominee name here has the support of type organization name here in pursuit of the office of type position title of the SNMMI-TS. We further acknowledge that we have received a copy of the job description for the office this candidate is seeking and understand the time commitment involved. We offer our support and wish them success in their pursuit.

Typed or P r i n t e d

n a m e

Signature

18 Attachment C

Position Statement President-Elect

In 250 words or less, please name three goals you would bring with you to the role of President-Elect of the SNMMI-TS.

type answer inside this box

Make sure you complete all sections of this form, and then send the completed version as an email attachment to the SNMMI central office at [email protected].

19 Attachment D

Position Statement (All Candidates other than President-Elect)

In 150 words or less, please answer the following question: How would you use your experience to be successful in this position?

type answer inside this box

Make sure you complete all sections of this form, and then send the completed version as an email attachment to the SNMMI central office at [email protected].

20 Date: June 1, 2018

To: All voting members of the SNMMI House of Delegates, all members of the Board of Directors, all Council Presidents, all Commission/Committee chairs, all committee members, all nominees for National offices, the Executive Board of the Technologist Section, and all voting members of the Technologists Section National Council.

From: Committee on Ethics

Re: Annual SNMMI Disclosure Review

SNMMI’s Disclosure of Potential Interest Policy is attached. Please read

this policy before filling out the accompanying SNMMI Disclosure of

Potential Conflicts of Interest Form.

If you have any questions about the SNMMI Disclosure of Potential Interest Policy or the Disclosure

of Potential Conflicts of Interest Form, please contact the Leadership Department at the Society’s

Headquarters:

703-708-9000 ext. 1227

Please return your completed form as soon as possible to

FAX 703-708-9020

As a scanned PDF to [email protected]

Thank you.

Attachments (3):  SNMMI Disclosure of Potential Interest Policy  SNMMI Disclosure of Potential Conflicts of Interest Form  SNMMI Disclosure of Potential Conflicts of Interest Form Attachment (SNMMI Corporate Database Roster)

21 Disclosure of Potential Interest Policy 2014-2015

Background SNMMI actively seeks and encourages the involvement of trusted, knowledgeable individuals in all of its decision-making, and encourages the expression of diverse views on important issues facing the practice and advancement of nuclear medicine. Most active members of the SNMMI belong to multiple organizations that have interests that overlap and sometimes conflict with the interests of the SNMMI.

Scope of the Policy This disclosure policy is designed to permit formal declarations of potential, perceived and real conflicts of interest as well as employment agreements in order to maximize, with appropriate safeguards, the participation of all SNMMI members in all of its activities. The policy applies to all members of the House of Delegates, all members of the Board of Directors, all Council Presidents and Board of Directors members, all committee/commission chairs and members, all nominees for National offices, the Executive Board of the Technologist Section, members of the Technologist Section National Council of Representatives, and Technologist committee chairs and members, collectively referred to as “SNMMI Leadership.”

Definitions

Fiduciary Responsibility Fiduciary responsibility of leaders of the SNMMI is the duty of loyalty to the organization. While duty of loyalty is a broad concept, and variously interpreted by statutes and the courts with respect to its application to not-for-profit organizations, SNMMI, generally defines duty of loyalty as requiring an individual to:

Place the interests of the Society of Nuclear Medicine above his/her personal interests and above the interests of other organizations when performing the duties of his/her elected or appointed Society of Nuclear Medicine office.

Disclosure Required The Society of Nuclear Medicine requires that all members of the SNMMI leadership complete disclosure forms covering both financial and non-financial topics at the time of their nomination, annually, and whenever potential conflicts of interest arise. In addition, members will disclose any potential conflict of interest before discussing the subject which involves a possible conflict of interest and will not participate in any action on that subject unless officially requested to do so by the body which is taking the action.

22 Discloser of Interest Policy Page 2

Disclosure of Financial Interests A financial conflict of interest is deemed to exist when a member of Society Leadership, and/or a member of his or her immediate family, has a direct or indirect financial interest in an organization, company or other entity and could materially benefit or be materially harmed by a decision or action taken by the SNMMI. Such direct or indirect financial interest includes receiving more than $5,000 per year in aggregate from an organization, company or entity as a result of:

1) consulting agreements 2) employment contracts 3) clinical trial agreements 4) royalties 5) grants 6) the receipt of honoraria or gifts from such organizations 7) any signed agreements that will generate guaranteed deferred compensation of $5,000 or more in a future year

In addition to the above disclosure of financial interests, any stock holdings valued at greater than $50,000 should be disclosed. Disclosure is similarly requested for all stock options and royalty rights, regardless of their apparent value.

Disclosure of Non-Financial Interests Non-financial conflicts of interest can arise when a member of SNMMI leadership serves in a fiduciary capacity in one or more organizations that compete for the same membership or product/service customer pool of the SNMMI, or that has conflicting goals on major policy issues with SNMMI.

Disclosure of Employment Agreements SNMMI leadership who have employment agreements or who are contractors of either Federal or state government and who are subject to fiduciary and/or financial restrictions shall disclose such agreements or contractual arrangements to the SNMMI. In addition, they are advised to disclose their activities, as needed, to their employer.

Implementation and Application of Disclosure Policy The Board of Directors shall have an open review of the disclosure forms of its members annually. The House of Delegates will appoint a disclosure review committee that will confirm that all voting members of the House of Delegates, all Council Presidents and all committee/commission chairs have completed their annual disclosure forms. In addition, this committee will review the forms to determine if there is the potential for a significant conflict of interest. The Executive Board of the Technologist Section will appoint a

23 disclosure review committee that will confirm that all voting members of the Executive

Board and the Technologists Section National Council have completed their annual disclosure forms. In addition, this committee will review the forms to determine if there is the potential for significant conflicts of interest.

24 SNMMI Disclosure of Potential Conflicts of Interest Form

Your Name:

Position in SNMMI (check all that apply):

 Board of Directors  House of Delegates  Nominee for National Office  Council/Center President  Council/Center Board Member  SNMMI Committee Chair  SNMMI-TS Executive Board  SNMMI-TS National Council  SNMMI-TS Committee Chair  SNMMI Committee Member  SNMMI-TS Committee Member  SNMMI Appointed Liaison

Non-Financial Disclosure Please check each organization in which you or immediate members of your family hold a leadership position (elected office or committee chair).

 AAPM (American Assn. of Physicists in Medicine)  ABNM (American Board of Nuclear Medicine)  ABSNM (American Board of Science in Nuclear Medicine)  ACNM (American College of Nuclear Medicine)  ACR (American College of Radiology)  ASNC (American College of Nuclear Cardiology)  EANM (European Association of Nuclear Medicine)  RSNA (Radiological Society of North America)  SRS (Society of Radiopharmaceutical Sciences)  WMIS (World Molecular Imaging Society)

Other 1. 2. 3. 4.

25 Financial Disclosures (Use the attached list of companies from the SNMMI corporate database as a guide.)

List the companies from which you or immediate members of your family:

 Receive more than $5,000 a year (aggregate annual sum per company) from consulting agreements, employment contracts, clinical trial agreements, royalties, grants, the receipt of honoraria or gifts

 Own stocks valued at greater than $50,000, or have stock options and royalty rights regardless of their apparent value.

Company

1. 2. 3. 4. 5. 6. 7. 8.

26 Employee Agreements Please indicate if you are an employee of the federal or a state government or if you have any employee agreement that may limit your participation in Society activities.

Federal Employee

State Employee (Name of state)

Statement of Compliance I have read the SNMMI Disclosure Review Policy and I understand that I am expected to comply with this policy. I agree that if the Society is considering any subject for which I have a potential conflict of interest, I will disclose my potential conflict of interest before I discuss the subject and I will not participate any action on that subject unless officially requested to do so by the body which is taking the action.

Signature:

27 SNMMI Disclosure of Potential Conflicts of Interest Form Attachment Corporate Roster

ABX advanced biochemical compounds DRAXIMAGE® ABX-CRO Advanced Pharmaceutical Eastern Isotopes/IBA Services Echelon AccSys Technology, Inc. Elsevier Accusync Medical Research Corporation Encore Global Imaging Solutions, Inc. Advance Molecular Imaging Inc. Faxitron X-Ray Corporation Advance Newsmagazines Fluoropharma Advanced Cyclotron Systems, Inc. Frontier Imaging, LLC Advanced Medical Resources Fujisawa Healthcare, Inc. AEA Technology QSA, Inc. Gamma Medica AirNet Express GE Healthcare Amici, Inc. Genzyme Corporation AnazaoHealth Corporation GlaxoSmithKline Anzai Medical Co. Ltd. Global Dosimetry Solutions, Inc. Applied Radiology Harpell Associates Inc. Areeda Associate Health Imaging & IT Associates in Medical Physics, LLC HealthCare Solutions, Inc. ATI Firth Sterling Hermes Medical Solutions, Inc. Aureus Medical Group Hitachi Medical Systems America, Inc. BC Technical, Inc. Ideas ASA Becquerel & Sievert Co., Ltd Imaging Technology News Berlex/Schering AG Germany Immunomedics, Inc. Best Medical International, Inc. International Isotopes Inc. Biodex Medical Systems IS2 Biodose LLC Isonics Corporation Biogen Idec Iso-Tex Diagnostics, Inc. BioNucleonics, Inc. Isotope Products Laboratories Bioscan, Inc. Ivy Biomedical Systems, Inc. Bracco Diagnostics, Inc. Jalorn Technical Services, Ltd. Bristol-Myers Squibb Medical Imaging Laboratory Impex Systems Ltd. BSI Lantheus Cambridge Isotope Laboratories Lippincott, Williams, & Wilkins Capintec, Inc. Macrocyclics, Inc. Cardinal Health Mallinckrodt Inc. Care Wise Medical Products MarCal Medical, Inc. Cedara Software MarCap Corporation Central Radiopharmaceutical Services, Inc. Marshall Isotopes Ltd. Charles River Laboratories MDX Corporation CIS-US, Inc Medi/Nuclear Corporation Codonics Medical Coaches Incorporated Comecer SRL Medical Imaging Electronics Cone Instruments Medical Imaging/Decisions In Imaging CSP Medical MedImage, Inc. CTI Molecular Imaging Medi-Nuclear Corporation Cyclomedical Applications Group LLC MEDI-PART, Inc. Cytogen Corporation Mediso Medical Imaging Systems Data Spectrum Corporation MEDX, Incorporated Daxor Corporation MIMvista Corporation Diagnostic Imaging Nationwide Medical Billing Resources Digirad Naviscan PET Systems, Inc. DMS Health Group neo-pet, LLC

28 News-Line for Radiology Professionals Shared PET Imaging, LLC Nordion Shell-USA, Division of SAI North American Scientific Siemens Medical Solutions USA Nuclear Fields Sirtex Medical, Inc. NukeMed, Inc. Springer Numa, Inc. SynterMed, Inc. NuView Taiyo Nippon Sanso Corporation Pet Scans of America Technology Imaging Services Philips Tema Sinergie Pinestar Technology, Inc. The Gollman Group, Inc. PMOD Technologies The PharmaLogic Group Positron Corporation Theragenics Corporation Promotech Thinking Systems Corporation R.W. Wiesener, Inc. Toshiba Radiology Today Trace Sciences International Corporation Radqual, LLC Trionix Research Laboratory, Inc. Raytest USA Unfors Instruments, Inc. RedRick Technologies, Inc. United Pharmacy Partners, Inc. Resources On Call Universal Medical Resources, Inc. Rotem Inc. Vita Medical Limited RSI Von Gahlen International, Inc. RWE NUKEM Gmbh Vulcan Nuclear SA Instruments, Inc. Wacom Technology Saint-Gobain Crystals Wako Chemicals Sam Young Unitech Co., LTD WellStar Health System Sanders Medical Products, Inc. Segami Corporation

29 Candidate CV Outline (CV MUST be completed in the outline specified below. Other formats will NOT be accepted)

NAME Candidate position SNMMI-TS Chapter

Professional Experience YEAR - YEAR (year started job – year ended job) Job Title Name of Institution City, State

Education YEAR (graduated) Degree Obtained Name of Institution City, State

Professional Board Certifications___ Example: 2005-Present Nuclear Medicine Technology Certification Board (NMTCB) – Certified PET

Activities in Society of Nuclear Medicine Technologist Section Example: 2010-2011 SNMMI-TS Nominating Committee Chair

Other Local or National Activities Relating to Nuclear Medicine:______Example: 2005 JRCNMT Site Visitor

Awards/Honors______Example: 2008 SNMMI-TS Leadership Academy Attendee

Memberships ______Example: 2010-Present American Society of Radiologic Technologists (ASRT)

Publications (# only)______Journal Articles: Books: Book Chapters: Invited Speaker Presentations: