ETHICS DISCLOSURE FORM FOR NOMINATORS SSA Leadership Positions Phone INSTRUCTIONS: PLEASE RETURN THIS FORM WITH THE NOMINATION PACKAGE NO LATER THAN THE SPECIFIED REQUESTED DATE. IF YOU HAVE QUESTIONS, CONTACT NAN BROADBENT, SSA EXECUTIVE DIRECTOR, AT NBROADBENT@SEISMOSOC.ORG . The Seismology Society of America (SSA) expects SSA Leaders to embody high standards of scientific integrity, personal accountability and ethics in their professional activities as set forth in SSA’s Professional Ethics Policy. Pursuant to the Professional Ethics Policy, SSA leaders includes members of the Board of Directors and committees as well as Associate Editors. In nominating someone to be an SSA leader, you play a vital role in upholding SSA’s professional ethics standards, and we ask that you supply the following information truthfully, to the best of your knowledge and ability. Nominee Information First Name * Last Name * Affiliated Institution * Please type the full name of your institution. Proposed SSA Leadership Role * Nominator’s Declarations 1. To the best of your knowledge, has a court, regulatory agency, employer, or other public or private entity issued a finding against the nominee in which their professional conduct was at issue, including any instances of “Prohibited Conduct” as defined in Section E of SSA’s Professional Ethics Policy? has a court, regulatory agency, employer, or other public or private entity issued a finding against the nominee in which their professional conduct No Yes 2. To the best of your knowledge, is the nominee currently under investigation by a court, regulatory agency, employer, or other public or private entity in which their professional conduct is at issue including any instances of “Prohibited Conduct” as defined in Section E of SSA’s Professional Ethics Policy? under investigation by a court, regulatory agency, employer, or other public or private entity in which their professional conduct No Yes Nominator’s Information & Acknowledgment First Name * Last Name * Email * Mobile Phone * Nominator's Acknowledgement * By submitting this form, you certify that you have answered the above questions truthfully. Date *
