Public Declaration of Interests /Confidentiality Undertaking /Consent to personal data processing for those collaborating with AIFA activities The present document consists of four parts, Personal Data, Public Declaration of Interests, Confidentiality Undertaking and Consent to personal data processing. All parts must be duly filled, signed and dated. Should the document be hand filled, make sure that any information is readable. Also not applicable or not pertinent fields have – to be crossed off in any case. PERSONAL DATA I, (Qualification) (First Name) (Surname) Country : Company / Institution: Business address: e-mail address: Aware of the contents of the Italian criminal legislation in the event of false declarations and forgery of documents according to I declare, under my own responsibility that I read the last section of art.76 of the Presidential Decree n. 445 of 28/12/2000, this document called and Instructions for Filling” and I have not other direct or indirect interests in the “Definition pharmaceutical industry in addition to those listed below . Table 1.Public Declaration of Interests From 0 to 3 NO Current Over 3 preavious years previous years Interests in pharmaceutical industry DIRECT INTERESTS: Employment with a company: mandatory pharmaceutical company in an executive role Employment with a company: in a lead role mandatory in the development of a medicinal product Employment with a company: other activities optional Consultancy for a company optional Strategic advisory role for a company optional Financial interests optional Ownership of a patent optional INDIRECT INTERESTS: Principal investigator optional Investigator optional Grant or other funding optional Family members interests optional The Experts who have a collaboration with the AIFA must declare the interests of members of the family of the expert (i.e. a spouse or a partner, children and parents) Signature: Date: ……………………………………… ………….……………………… Table 2. DETAILS OF PUBLIC DECLARATION OF INTERESTS (Fill this part if you have filled any grey box in table n. 1, otherwise cross off the following boxes anyway) Period of activity Company or Products Therapeutic Institution List all products for trial Indication you are responsible
Public Declaration of Interests /Confidentiality Undertaking /Consent to personal data processing for those collaborating with AIFA activities The present document consists of four parts, Personal Data, Public Declaration of Interests, Confidentiality Undertaking and Consent to personal data processing. All parts must be duly filled, signed and dated. Should the document be hand – filled, make sure that any information is readable. Also not applicable or not pertinent fields have to be crossed off in any case. PERSONAL DATA I, (Qualification) (First Name) (Surname) Country : Company / Institution: Business address: e-mail address: Aware of the contents of the Italian criminal legislation in the event of false declarations and forgery of documents according to art.76 of the Presidential Decree n. 445 of 28/12/2000, I declare, under my own responsibility that I read the last section of this document called “Definition and Instructions for Filling” and I have not other direct or indirect interests in the pharmaceutical industry in addition to those listed below . Table 1.Public Declaration of Interests Interests in pharmaceutical industry NO Current From 0 to 3 previous years Over 3 preavious years DIRECT INTERESTS: Employment with a company: pharmaceutical company in an executive role mandatory Employment with a company: in a lead role in the development of a medicinal product mandatory Employment with a company: other activities optional Consultancy for a company optional Strategic advisory role for a company optional Financial interests optional Ownership of a patent optional INDIRECT INTERESTS: Principal investigator optional Investigator optional Grant or other funding optional Family members interests optional The Experts who have a collaboration with the AIFA must declare the interests of members of the family of the expert (i.e. a spouse or a partner, children and parents) Signature: ……………………………………… Date: ………….……………………… Table 2. DETAILS OF PUBLIC DECLARATION OF INTERESTS (Fill this part if you have filled any grey box in table n. 1, otherwise cross off the following boxes anyway) Period of activity Company or Institution Products List all products for you are responsible Therapeutic Indication trial
Declaration%20of%20interest_Eng.docx