Elections

Since becoming a member of OMA, have you engaged in any activity that may have been a misrepresentation of your official position, title, or professional qualifications? If yes, state the particulars. _________________________________________________________________________________________________ If elected and seated as a member of the Ethics Committee, how would you react to a committee decision with which you personally strongly disagreed? _________________________________________________________________________________________________ Do you think you may have a potential conflict of interest or commercial involvement as outlined in the OMA Conflict of Interest Policy and Disclosure Statement that may prevent you or may be perceived by others as not allowing you to act solely in the best interest of the OMA while serving on the Ethics Committee? If so, please provide a detailed overview on your disclosure form. _________________________________________________________________________________________________ All Ethics Committee candidates are asked to provide OMA with the proper authorization for a standard criminal, professional and education background check. Will you consent to a standard background check? _________________________________________________________________________________________________

Please indicate your level of competence in the following areas (10 being the highest, 1 being the lowest).

Ethical Assessment Skills Ability to recognize and discuss moral conflicts. Ability to understand the moral perspectives of all parties. Ability to explain the ethical dimension of a case. Ability to formulate and justify morally acceptable solutions.

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Operational Skills Facilitation skills Mediation skills Interpersonal Skills Active listening Communication skills

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Advocacy skills

Signature: ____________________________________ Date: __________________

How and What to Submit: Return this fully completed application to OMA by September 30, 2021. Email: election@obesitymedicine.org Mail: 7173 S Havana St, Suite 600-150 Centennial, CO 80112 Only fully completed applications will be considered for review.