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HFSA Committee Application Form
Please respond to all of the required questions and click 'Next Page' to proceed. If you would like to save your progress and return later, enter your email address in the appropriate field on the Personal Information page, tab out of that field and click 'Save Progress' at the bottom of the page. You will be sent an email with a link to open the form. When you have completed this online application form, click 'Submit Application' on the Submission page, and the Nominations Committee will consider you for committee appointment.

Contact Information

e.g. MD, PhD, etc.

Professional Information
Please identify your Discipline (select all that apply):

HFSA Committee Application Form
Please respond to all of the required questions and click 'Next Page' to proceed. If you would like to save your progress and return later, enter your email address in the appropriate field on the Personal Information page, tab out of that field and click 'Save Progress' at the bottom of the page. You will be sent an email with a link to open the form. When you have completed this online application form, click 'Submit Application' on the Submission page, and the Nominations Committee will consider you for committee appointment.

Membership Information
If you are not a current member, you are NOT allowed to submit a Committee Application form.

Please click 'Save Progress' at the bottom of this page - you will be sent an email containing a link to reopen this form. When your HFSA membership dues are paid up-to-date, change the response for the above question to "Yes" and fill out the rest of this form. 
Indicate other society memberships you have (select all that apply):

HFSA Committee Application Form
Please respond to all of the required questions and click 'Next Page' to proceed. If you would like to save your progress and return later, enter your email address in the appropriate field on the Personal Information page, tab out of that field and click 'Save Progress' at the bottom of the page. You will be sent an email with a link to open the form. When you have completed this online application form, click 'Submit Application' on the Submission page, and the Nominations Committee will consider you for committee appointment.

Committee Preferences
In the fields below, please select your first, second, and third choices of committees to apply for. A first choice is required; a second and third are optional, but preferred. You cannot choose the same committee more than once.

The following 9 committees are accepting applications this year:
  • Board of Directors
  • Development Committee
  • Early Career Committee
  • International Committee
  • Lifetime Achievement Committee
  • Membership Committee
  • Nursing Committee
  • Publications and Scientific Statements Committee
  • Research Committee
First Choice Committee

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Second Choice Committee

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Third Choice Committee

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HFSA Committee Application Form
Please respond to all of the required questions and click 'Next Page' to proceed. If you would like to save your progress and return later, enter your email address in the appropriate field on the Personal Information page, tab out of that field and click 'Save Progress' at the bottom of the page. You will be sent an email with a link to open the form. When you have completed this online application form, click 'Submit Application' on the Submission page, and the Nominations Committee will consider you for committee appointment.

Attachments
Please upload an electronic copy of your CV.

YOU CANNOT LEAVE THIS PAGE UNTIL FILES ARE UPLOADED. If you do not currently have an electronic copy of your CV, click the 'Save Progress' button at the bottom of this page. Your form will be saved and you will be sent an email containing a link, which will allow you to return to this form whenever you are able to upload files. QUESTIONS - please call:  301.312.8635.
Upload

HFSA Committee Application Form
Please read the HFSA Conflict of Interest Disclosure Policy below and determine if you have any conflicts to disclose.

HFSA Conflict of Interest Policy
For Officers, the Board of Directors, and Committee Members

Heart Failure Society of America (HFSA) requires that all officers, the Board of Directors, and committee members (hereinafter collectively referred to as Members) disclose all relationships with commercial entities (hereinafter collectedly referred to as Organizations) whose products or services are related to the goals of HFSA. These relationships may constitute real or perceived conflicts of interest and have the potential to influence the way Members carry out their responsibilities. This disclosure policy is designed to protect the reputation and integrity of HFSA.

The following relationships should be disclosed:  those with Organizations on the part of the Member or the Member’s spouses/partners, and dependents during the past 12 months:

  1. Honoraria / Speaker’s Bureau:  including honoraria from a third party, gifts or in-kind compensationfor speaking
  2. Consultant / Advisory Board:  consulting, travel, scientific advisory board service, legal testimony or consultation, or other purpose
  3. Equity interests / Stock Options (or entitlement to the same) including a non-publicly traded company
  4. Royalty Income / Intellectual Property Rights or the right to receive future royalties under a license or copyright, where the topic is directly related to the licensed technology or work under discussion
  5. Officer / Trustee / Director
  6. Ownership / Employment
  7. Research Grants / Fellowships Support from a commercial entity

If you are aware of any other relationships with Organizations that might be perceived by others as potentially influencing your objectivity in any HFSA matters in which you are involved, please disclose such relationships pursuant to the procedures described below.

Members are required to file a signed Disclosure Form not less than annually and on such other occasions as requested by the CEO, Board of Directors or Ethics Committee. Disclosure Forms must be completed and signed at the time of appointment to the Board of Directors or any HFSA committee. Members must disclose any new relationships that arise after submission of the Disclosure Form.

The Disclosure Form will be reviewed by the CEO and may be reviewed by the Ethics Committee (collectively, the Reviewing Body) to determine whether a conflict of interest exists. As a result of the review, further inquiries may be made. In the event that a Member fails to provide requested information or when it is determined that an unresolvable conflict of interest exists, the Reviewing Body is authorized to make a recommendation to the Board of Directors regarding a Member’s continuing role and participation as an officer, member of the Board of Directors, or member of a committee of HFSA. It may be recommended that a Member’s participation in some matters may be modified or, in certain circumstances, discontinued. The Board of Directors shall have the authority to make the final decision as to a Member’s continuing role and participation in HFSA.

When a Member’s participation in HFSA involves a matter relating to an Organization with which a relationship exists, he or she should leave the meeting for the duration of the discussion. The Member’s departure will be noted in the meeting minutes.

The responsibility for identifying and disclosing relationships rests with the Member. Questions should be addressed to the CEO.

Disclosure Information
In the grid below, add a row for each Company with which you have a relationship(s) to disclose.
  Company1. Honoraria, Speaker's Bureau2. Consultant, Advisory Board3. Equity Interests, Options4. Royalties, Intellectual Prop. Rights5. Officer, Trustee, Director6. Ownership, Employment7. Research Grants, Fellowship Support  
Export Clear Add new row
1

You can expand this field by clicking and dragging at the bottom-right corner.

HFSA Disclosure Agreement
It is my understanding that this information will be retained in HFSA files and will be available for review by the CEO, members, prospective members and others who inquire. I further understand that this information may be shared with HFSA's legal council and Ethics Committee. I acknowledge that it is my responsibility to ensure that my disclosure information is current and complate and to update my disclosure records throughout the year if my relevant relationships change.

HFSA Committee Application Form
Thank you for choosing to support and represent HFSA as a committee member. As a member driven society your time, effort and commitment are key factors in the continued growth and success of HFSA.

The HFSA Nominations Committee will review every application and take efforts to place you in one of the three committees you identified. HFSA has numerous committees, however the number of positions on each is limited to maintain efficient operations. Final committee appointments will be confirmed in June and a member of the HFSA staff will contact you with results and/or next steps.
Click 'Submit Application' at the bottom of this page to submit your form. The HFSA Nominations Committee will conduct its review and assignment processes, and notify you of the results via email. Thanks for applying!
You have indicated that your membership dues are not paid up-to-date. Please save you progress and return later - you will be allowed to submit this form when you indicate that your membership is current.

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