Fillable Printable Declaration of Interests for WHO Experts
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
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.
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
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?
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
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?
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
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?
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
Nos. 1 - 4:
Type of interest, question
number and category (e.g.,
Intellectual Property 4.a
Belongs to you, a
unit or other?
Amount of income
or value of interest
(if not disclosed, is
assumed to be
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.
. 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)