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BHIVA competing interest disclosure form (BHIVA subcommittee/judging panel member)

This form is for submissions to BHIVA of competing interest disclosures. If you have any queries, please contact the Secretariat at [email protected].

BHIVA subcommittee/ judging panel member

This form is for BHIVA subcommittee or judging panel members who are required to make a disclosure of any competing interests, including financial, non-financial interests and membership of other committees. This is done retrospectively for the preceding 12 months – please see the email request for the time period of this declaration and insert the relevant dates below.

Please report all relationships with pharmaceutical, diagnostic, or such similar companies involved in HIV-related products in the preceding 12 months. For the purposes of this disclosure, you should declare all interests, including business and personal interests of their spouse, partner, family and close relatives (defined as “member” in this declaration).

You do not need to specify any company names or individual amounts at this stage. The Chair of the relevant subcommittee or judging panel will review all submissions and may contact you directly for more details, if necessary. Details given will be retained on a register at the Secretariat and will be made available for publication, if required.

Please complete all sections of this form. If there is nothing to disclose in any section, please indicate ‘£0’ or ‘none’.

 

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Your details
Period covered

Declaration: No signature is required; however, by completing and submitting this form, I declare that this is an accurate reflection of all interests that may impact on my work as a BHIVA trustee.

Declaration of financial interests

Consultancy work
This refers to any paid retainer or agreement between the member and a company usually with a contract for a specific period and includes payment for attending Advisory Board meetings.

Consultancy work

Speaker fees
This mainly concerns fees (e.g. for lectures, commissioned articles or other suchlike paid activity) received from a commercial sponsor and where the member has benefited personally.

Speaker fees

Company shares
This includes any shares held by the member in the biomedical industry (e.g. pharmaceutical, diagnostic or similar companies).

Company shares

Grant support
This refers to fees and grants paid to the member which have been used for research, education, equipment, salaries (including fellowships) in your department and for personal travel/hospitality for conferences and meetings.

Grant support

Other paid income
This refers to patents or royalties, serving as an expert witness, or performing other activities for an entity with a financial interest in this area undertaken by the member.

Other paid income

Other relevant disclosure
This refers to any other relationship which is financial or with an organisation that, if not disclosed by the member, could compromise the member or BHIVA as a charitable organisation.

Other relevant disclosure
Declaration of non-financial interests

You are required to declare any trusteeships in non-BHIVA organisations and non-BHIVA committee memberships or directorships, which have conflicting or competing interests. Please ensure that you give full information regarding dates and length of term. Please mark ‘none’ if there is nothing to disclose.

Trusteeships
Give full name of organisation(s), plus term served to date and retirement date.

Committee memberships
Give full name of organisation(s) and indicate your role on any committees, giving details of term served to date and retirement date.

Directorships
Give full name of organisation(s), plus term served to date and retirement date.