ETHICS DISCLOSURE FORM FOR NOMINATORS – Honors & Awards Company INSTRUCTIONS: PLEASE COMPLETE THIS FORM AS PART OF YOUR HONORS NOMINATION PACKAGE. WHEN YOU PRESS SUBMIT, THE FORM IS AUTOMATICALLY SENT TO THE AWARDS COMMITTEE. (NO NEED TO CREATE/INCLUDE A COPY WITH THE REST OF YOUR NOMINATION PACKAGE.) QUESTIONS? CONTACT NAN BROADBENT, SSA EXECUTIVE DIRECTOR, AT NBROADBENT@SEISMOSOC.ORG. The Seismology Society of America (SSA) expects the recipients of awards and honors to embody high standards of scientific integrity, personal accountability and ethics in their professional activities as set forth in SSA’s Professional Ethics Policy. In nominating someone for an SSA award or honor, you play a vital role in upholding SSA’s professional ethics standards. All SSA awards and honors are determined and issued at SSA’s sole judgment and discretion and SSA retains the right to grant, defer, or decline to grant an award or honor to any person. SSA also retains the right to revoke an award or honor already granted, if, in its judgment and discretion, SSA determines that it is in SSA’s best interests to do so. Nominee Information First Name * Last Name * Affiliated Institution * Begin typing the name of the institution to locate it within the database. If the institution name does not appear, please type the full institution name to add it to our database. Honor or Award being proposed * 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 *
