REVOCATION REQUEST FORM Company The Seismology Society of America (SSA) expects SSA members and awardees to embody high standards of scientific integrity, personal accountability and ethics in their professional activities as set forth in SSA’s Professional Ethics Policy (the Ethics Policy). In the rare case where a member or awardee no longer meets this expectation, SSA will in its sole discretion consider revoking the individual’s status as a member or rescinding any awards that have been granted in cases of proven scientific misconduct, serious breaches of professional ethics or when the member or awardees in the view of SSA otherwise no longer merits the status of membership or the privileges of being an awardee. Please read SSA’s Membership & Awards Revocation Procedures for the requirements necessary to submit a revocation request. Only SSA members may submit a request. Please complete all fields and submit via email to SSA’s Executive Director, Nan Broadbent at nbroadbent@seismosoc.org. Direct any questions to the Executive Director via email. Individual Making this Request First Name * Last Name * Email * Are you an SSA Member? * Yes No Person Reported to Have Engaged in Misconduct (the “Respondent”) 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. Documentation Requirements All revocation requests must include an investigative report that documents findings, sanctions or actions taken from an independent organization or agency. Alternatively, a public announcement of the information in a report, or actions that have been taken, may be submitted. Media reports alone may not be sufficient to support a revocation request. SSA will only consider requests for revocation filed within four years of the publication of the report or announcement of the finding, sanction, or action. SSA will not consider requests against deceased individuals. List the documentation being submitted to support this revocation request, i.e., investigative report and/or public announcement of actions taken * Include links to the documentation listed above in response to the previous question * Attach documentation listed above in response to the previous question. If you have more than 4 files, please contact us at nbroadbent@seismosoc.org. Attach documentation listed above in response to the previous question Attach documentation listed above in response to the previous question Attach documentation listed above in response to the previous question Attach documentation listed above in response to the previous question Optional Comments/Confidentiality Please be aware that any comments you share here may be provided to the Ethics Committee and Board of Directors as they consider the request and will also be provided to the Respondent, should the request proceed to the Ethics Committee review stage. Your name will not be shared with the Respondent, the Ethics Committee or the Board of Directors, but please be cautious of including any identifying information about yourself or others. SSA expects you to maintain the confidentiality of this matter until its conclusion. Confidentiality * Please acknowledge that you have read the confidentiality statement included above and agree to abide by it Please share any additional comments (optional): Date *
