Fillable Printable Declaration of Interests for WHO Experts

Declaration of Interests for WHO Experts

DECLARATION OF INTERESTS FOR WHO EXPERTS

WHO's work on global health issues requires the assistance of external experts who may have interests related to

their expertise. To ensure the highest in tegrity and pub lic confiden ce in its activities, WHO requires that ex perts serving in an

advisory role disclose any circumstances that could give rise to a potential conflict of interest related to the subject of the

activity in which th ey will be involved .

All experts serving in an advisory role must disclose any circumstances that could represent a potential conflict of

interest (i.e., any interest that may affect, or may reasonably be perceived to affect, the expert's objectivity and independence).

You must disclose on this Declaration of Interest (DOI) form any financial, professional or other interest relevant to the subject

of the work or meeting in which you have been asked to participate in or contribute towards and

any interest that could be

affected by the outcome of the meeting or work. You must also declare relevant interests of your immediate family members

(see definition below) and, if you are aware of it, relevant interests of other parties with whom you have substantial common

interests and which may be perceived as unduly influencing your judgement (e.g. employer, close professional associates,

administrative unit or department).

Please complete this form and submit it to WHO Secretariat if possible at least 4 weeks but no later than 2 weeks

before the meeting or work. You must also promptly inform the Secretariat if there is any change in this information prior to,

or during the course of, the meeting or work. All experts must complete this form before participation in a WHO activity can

be confirmed.

Answering "Yes" to a question on this form does not automatically disqualify you or limit your participation in a

WHO activity. Your answers will be reviewed by the Secretariat to determine whether you have a conflict of interest relevant

to the subject at hand. One of the outcomes listed in the next paragraph can occur depending on the circumstances (e.g, nature

and magnitude of the interest, timeframe and duration of the interest).

The Secretariat may conclude that no potential conflict exists or that the interest is irrelevant or insignificant. If,

however, a declared interest is determined to be potentially or clearly significant, one or more of the following three measures

for managing the conflict of interest may be applied. Th e Secretariat (i) allows full participation, with public disclosure o f your

interest; (ii) mandates partial exclusion (i.e., you will be excluded from that portion of the meeting or work related to the

declared interest and from the corresponding decision making process); or (iii) mandates total exclusion (i.e., you will not be

able to participate in any part of the meeting or work).

All poten tially significant interests will be disclosed to the other participants at the start of the activity an d you will be

asked if there have been any changes. A summary of all declarations and actions taken to manage any declared interests will

be published in resulting reports and work products. Furthermore, if the objectivity of the work or meeting in which you are

involved is subsequently questioned, the contents of your DOI form may be made available by the Secretariat to persons

outside WHO if the Director-General considers such disclosure to be in the best interest of the Organization, after consulting

with you. Completing this DOI form means that you agree to th ese conditio ns.

If you are unable or unwilling to d isclose the de tails of an interest that may pose a real or pe rceived conflict, you must

disclose that a conflict of interest may exist and the Secretariat may decide that you be totally recused from the meeting or

work concerned, after consulting with you.

Name:

Institution:

Email:

Date and title of meeting or work, including description of subject matte r to be considered (if a number of

substances or processes are to be evaluated, a list should be attached by the organizer of the activity):

Member of Guidelines Developing Group on Nanohealth 2011

Please answer each of the questions below. If the answer to any of the questions is "yes", briefly describe

the circumstances on the last page of the form.

The term "you

" refers to yourself and your immediate family members (i.e., spouse (or partner with whom

you have a similar close personal relationship) and your children). "Commercial entity

" includes any commercial

business, an industry association, research institution or other enterprise whose funding is significantly derived

from commercial sources with an interest related to the subject of the meeting or work. "Organization

" includes a

governmental, international or non-profit organization. "Meeting

" includes a series or cycle of meetings.

EMPLOYMENT AND CONSULTING

Within the past 4 years, have you received remuneration from a commercial entity or

other organization with an interest related to the subject of the meeting or work?

1a Employment Yes

1b Consulting, including service as a technical or other advisor Yes

RESEARCH SUPPORT

Within the past 4 years, have you or has your research unit received support from a

commercial entity or other organization with an interest related to the subject of the

meeting or work?

2a Research support, including grants, collaborations, sponsorships, and other funding Yes

2b Non-monetary support valued at more than US $1000 overall (include equipment,

facilities, research assistant s, paid travel to meetings, etc.)

Support (including honoraria) for being on a speakers bureau, giving speeches or training

for a commercial entity or other organization with an interest related to the subject of the

meeting or work?

Yes

INVESTME NT INTERESTS

Do you have current investments (valued at more than US $10 000 overall) in a

commercial entity with an interest related to the subject of the meeting or work? Please

also include indirect investments su ch as a trust or holding company. You may

exclude mutual funds, pension funds or similar investments that are broadly diversified

and on which you exercise no control.

3a Stocks, bonds, stock options, other securities (e.g., short sales) Yes

3b Commercial business interests (e.g., proprietorships, partnerships, joint ventures, board

memberships, controlling interest in a company) Yes

INTELLECTUAL PROPERTY

Do you have any intellectual property rights that might be enhanced or diminished by

the outcome of the meeting or work?

4a Patents, trademarks, or copyrights (including pending applications) Yes

4b Proprietary know-how in a substance, technology or process Yes

PUBLIC STATEMENTS AND POSITIONS (during the past 3 y ears)

5a As part of a regulatory, legislative or judicial process, have you provided an expert

opinion or testimony, related to the subject of the meeting or work,

for a commercial entity or other organization?

Yes

5b Have you held an office or other position, paid or unpaid, where you represented interests

or defended a position related to the subject of the meeting or work? Yes

ADDITIONAL INFORMATION

6a If not already disclosed above, have you worked for the competitor of a product that is the

subject of the meeting or work, or will your participation in the meeting or work enable

you to obtain access to a competitor's confidential proprietary information, or create for

you a personal, professional, financial or business competitive advantage? Yes

6b To your knowledge, would the outcome of the meeting or work benefit or adversely

affect interests of others with whom yo u have substantial common personal, professional,

financial or business interests (such as y our adult children or siblings, close professional

colleagues, administrative unit or department)? Yes

6c Excluding WHO, has any person or entity paid or contributed towards your travel costs in

connection with this WHO meeting or work? Yes

6d Have your received any payments (other than for travel costs) or honoraria for speaking

publicly on the subject of this WHO meeting or work?

Yes

6e Is there any other aspect of your bac kground or present circu mstances not addressed

above that might be perceived as affecting your objectivity or independence? Yes

TOBACCO OR TOBACCO PR ODUCTS (answer without regard to relevance to the

subject of the meeting or work)

Within the past 4 years, have you had employment or received research support or other

funding from, or had any other professional relationship with, an entity directly involved

in the production, manufacture, distribution or sale of tobacco or tobacco products or

representing the interests of any such entity? Yes

EXPLANATION OF "YES" RESPONSES: If the answer to any of the above questions is "yes", check

above and briefly describe the circumstances on this page. If you do not describe the n ature of an interest or

if you do not provide the amount or value involved where relevant, the conflict will be assumed to be

significant.

Nos. 1 - 4:

Type of interest, question

number and category (e.g.,

Intellectual Property 4.a

copyrights) and

basic

descriptive details.

Name of

company,

organization, or

institution

Belongs to you, a

family member,

employer, research

unit or other?

Amount of income

or value of interest

(if not disclosed, is

assumed to be

significant)

Current

interest (or

year ceased)

Nos. 5-6: Describe the subject, specific circumstances, parties involved, time frame and other relevant details

CONSENT TO DISCLOSURE

. By completing and signing this form, you consent to the disclosure of any

relevant conflicts to other meeting participants and in the resulting report or work product.

DECLARATION

. I hereby declare on my honour that the disclosed information is true and

complete to the best of my knowledge.

Should there be any change to the above information, I will promptly notify the responsible staff of

WHO and complete a new declaration of interest form that describes the changes. This includes any change

that occurs before or during the meeting or work itself and through the period up to the publication of the

final results or completion of the activity concerned.

Date: ________________ Signature________________________________

WHO 850 E LEG (16/06/2010)