GPAC Conflict of Interest Declaration

Help
Any person participating as a member of a Guidelines and Protocols Advisory Committee (GPAC) working group must complete this Conflict of Interest Declaration before their membership will be confirmed by the GPAC Executive Committee.

Any person participating as a member of a Guidelines and Protocols Advisory Committee (GPAC) working group must complete this Conflict of Interest Declaration before their membership will be confirmed by the GPAC Executive Committee.

Answer all questions truthfully and to the best of your knowledge. Full disclosure of all real, potential or perceived conflicts of interest is necessary to manage them appropriately during the development process. If you have any doubts about a potential conflict of interest, it is better to disclose an interest or relationship than not to do so.

By completing and signing this form, you are consenting to disclosure of any relevant conflicts of interest to the GPAC Executive Committee, the working group and chair, medical consultants, and relevant Ministry of Health staff. 

Missing or incorrect value
Missing or incorrect value
Missing or incorrect value

Direct Financial Interests

1. Employment and Consulting 
In the past three years, have you or a member of your immediate family (parent, spouse, child or sibling) received remuneration from a commercial entity or other organization whose products or services may be recommended in the guideline being developed by the working group? 
a) Employment
Missing or incorrect value
b) Consulting, including services as a technical advisor
Missing or incorrect value
c) Honouraria or fees for participating on a speakers panel, giving lectures, or training
Missing or incorrect value

 

2. Investment Interests
Do you or a member of your immediate family (parent, spouse, child or sibling) have current investments in in a commercial entity with an interest related to the subject of the guideline?
Please include indirect investment such as a trust or holding company. You may exclude mutual funds, pension funds or similar investment that are broadly diversified and/or over which you exercise no control.
 
a) Stocks, bonds, stock options, other securities
Missing or incorrect value
b) Commercial business interests (e.g. proprietorships, partnerships, joint ventures, board memberships, controlling interest in the company)
Missing or incorrect value

 

3. Intellectual Property
Do you or a member of your immediate family (parent, spouse, child or sibling) have any intellectual property rights that could be influenced by recommendations in the guideline?
 
a) Patents, trademarks, or copyrights (including pending applications)
Missing or incorrect value
b) Proprietary information for a substance, technology or procedure
Missing or incorrect value

Indirect Interests

4. Research Support and Academic Advancement
In the past three years, have you or your research organization received research support, including grants, collaborations, sponsorships and other funding, from a commercial entity or other organization whose products or services may be recommended in the guideline being developed by the working group?
Missing or incorrect value
Have you previously published on a topic that expresses an opinion on the effectiveness of an intervention that may be recommended in the guideline being developed by the working group?
Missing or incorrect value
Are you actively conducting research on a topic that could be affected by the recommendations in the guideline?
Missing or incorrect value

 

5. Clinical Revenue Streams
Other than the BC Medical Services Plan, do you receive other clinical revenue related to the subject matter of the guideline?Missing or incorrect value
Could your clinical revenue stream be significantly influenced by a recommendation in the guideline?Missing or incorrect value

 

6. Other Positions and Relationships
Have you held an office, board membership or other position (paid or unpaid) where you represented interests or defended a position related to the subject of the guidelines?
Missing or incorrect value
Do you have any other relationships that could be seen by a reasonable, well‐informed participant as having the potential to influence your input on the content of the guideline?
Missing or incorrect value

Declaration

I am not aware of any actual, potential or perceived conflicts of interest with respect to my involvement with a GPAC Working group.
If any circumstances change and/or come to my attention regarding my real, potential or perceived conflict of interest, or a real or potential perception of bias on my behalf, I will notify the working group chair or a GPAC co-chair immediately.
Confidentiality Statement:
This Declaration will be retained by the Guidelines and Protocols Advisory Committee and the information used only for the purpose of determining if a conflict of interest exists. If you have any questions about the collection of this information, please contact your Research Officer.

Keep a Copy for Your Records

If you want to keep a copy for your records, you can download a copy using the PDF button below.
HLTH 8126   2024/02/06
8ced0743c0b37eb1fef0dd9aae9c8f2c354a909d
Confirm
Form Submitted
Review Form Validation Messages
Unable to complete action
Confirmation
Confirmation
Create link to share