I 1. DATE: NAME: SIGNATURE: Conflict of Interest Disclosure Form Schedule 2 – (Reference: COI Guidelines Section 5.4) Disclosures are required under Section 5.4 of the Conflict of Interest Guidelines for those activities or interests involving any Party during the past two years which benefited the Member, their immediate family members, or the department or organization for which they have managerial responsibility, particularly as the activities relate to the following areas (add pages as necessary): For each Party and drug, technology or topic, identify the type of funding or benefit received and indicate the total value (dollar range). Check () type of benefit / interest as Check () dollar range appropriate as appropriate Name of Party Drug, technology or involved and year Value of benefit or interest (see section 2.2 for definition) of funding chairs) grants or funding or funds) Options (endowed $10,000 Advisor academic mutual Stock funding education $50,000 as for $10,000 than - or - $50,000 $5,000 more - Over Employment Payment Consultant Research Payment Personal Stocks of appointments $0 $5,001 $10,001 (excluding
I 1. DATE: NAME: SIGNATURE: Conflict of Interest Disclosure Form – Schedule 2 (Reference: COI Guidelines Section 5.4) Disclosures are required under Section 5.4 of the Conflict of Interest Guidelines for those activities or interests involving any Party during the past two years which benefited the Member, their immediate family members, or the department or organization for which they have managerial responsibility, particularly as the activities relate to the following areas (add pages as necessary): For each Party and drug, technology or topic, identify the type of funding or benefit received and indicate the total value (dollar range). Check () type of benefit / interest as appropriate Check () dollar range as appropriate Name of Party (see section 2.2 for definition) Drug, technology or involved and year of funding Employment Payment as Advisor or Consultant Research funding or grants Payment for academic appointments (endowed chairs) Personal education funding Stocks or Stock Options of more than $10,000 (excluding mutual funds) Value of benefit or interest $0 - $5,000 $5,001 - $10,000 $10,001 - $50,000 Over $50,000
pcodr-coi-guidelines-form.docx