DECLARATION OF CONFLICT OF INTEREST FORMAT
Please fill out this form under oath in compliance with IETS transparency and institutional integrity policies.
Important regulatory considerations:
• Healthcare industry: Pharmaceutical or health technology manufacturers, health benefit plan administrators (EAPB), healthcare providers (EPS/IPS) where you hold executive or advisory positions.
• Family member: Consanguinity up to 4th degree (cousins), affinity up to 2nd degree (in-laws), civil up to 1st degree (adopted children/adoptive parents), spouse or permanent partner.
1Do you receive or have you received financial support to attend meetings, conferences or educational activities (registrations, travel grants, etc.) from the healthcare industry? *
2Do you receive or have you received fees as a speaker at meetings organized by the healthcare industry? *
3Have you received financial support from the healthcare industry for training or educational programs? *
4Do you receive or have you received consulting or advisory fees from the healthcare industry? *
5Have you participated in research funded by the healthcare industry as sponsor or via donation of supplies/medications? *
6Does the institution where you work receive financial support from the healthcare industry? *
7Do you have commercial interests or own shares in healthcare companies? *
8Are you an author of or hold patents related to health technologies, diagnostics, or medications? *
9Does any family member have work, professional, or commercial ties with the healthcare industry? *
10Do you belong to patient associations, advocacy groups, or scientific societies funded by the healthcare industry? *
11Have you expressed public opinions (media, social networks, legal actions) advocating for or against technologies under evaluation? *
12Have you acted as principal investigator or co-investigator in primary studies on technologies under assessment? *
13Is there any other circumstance, interest, or relationship you consider relevant to disclose? *