ESAIC Guidelines – Conflict of Interest and Confidentiality Agreement
Please complete this form to disclose any potential conflicts of interest (COI) or involvement relevant to the development of the specified guideline(s).
It is the responsibility of the signer to fill in an updated COI Disclosure form in the case that the Affiliation or Financial interest situation has changed. Please inform us about any of the following:
Conflict of interest:
A situation in which a reasonable person would consider that an individual’s judgments or actions regarding any aspect of the guideline development process is, or could be perceived to be, influenced by an outside interest.
Financial Interest:
A position or relationship held by an individual that offers potential gain or loss of monetary value, such as employment, stock ownership,payment for services, or gifts given with the expectation of reciprocity.
Direct financial interest:
A financial interest that is owned by the individual or received directly by the individual.
Indirect financial interest:
A financial interest that is owned or received via an intermediary,e.g., research funding to an individual received through the individual’s academic institution.
Name
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First Name
Last Name
Affiliation
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In which guidelines are you currently involved?
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Fasting guidelines
Sedation guidelines
Respiratory support in the obese patient guidelines
Preoperative evaluation of the cardiac patients guidelines
Pain guidelines
Tracheostomy guidelines
End of life Task Force
Other
Section I - Direct and indirect financial interests
1. Have you or your spouse/partner received in the previous 3 years or anticipate receiving in the next 12 months: Income to participate in a study on an intervention that is subject tothis/these guideline(s)? This includes fees, travel,accommodation, meals, gifts, car lease, electronics, equipment, etc.
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Yes
No
If yes, please specify and add to which guidelines it refers
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2. Have you or your spouse/partner received in the previous 3 years or anticipate receiving in the next 12 months: Any income to provide consultancy for a manufacturer of a technology or intervention relevant to this/these guideline(s)? This includes fees (honoraria, consultation fees, participation to company sponsored bureau), travel, accommodation, meals, gifts, car lease, electronics,equipment, etc.
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Yes
No
If yes, please specify and add to which guidelines it refers
*
3. Have you or your spouse/partner received in the previous 3 years or anticipate receiving in the next 12 months: Payment for lectures and/or meeting attendance in support of a technology or intervention relevant to this/these guideline(s)? This includes fees, travel, accommodation, meals, gifts, car lease, electronics,equipment, etc.
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Yes
No
If yes, please specify and add to which guidelines it refers
*
4. Have you or your spouse/partner received in the previous 3 years or anticipate receiving in the next 12 months: Payment for board membership, patent applications and/or research support and/or research grants (restricted or unrestricted) for a technology or intervention relevant to this/these guideline(s)? This includes fees, travel, accommodation, meals, gifts, car lease, electronics,equipment, etc.
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Yes
No
If yes, please specify and add to which guidelines it refers
*
5. Do you or your spouse/partner have any ownership interest (e.g.Shares) in a company that produces technology or interventions relevant to this/these guideline(s)?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
6. Have you or your spouse/partner any other current or recent (within the past 3 years) support, direct or indirect financial interests with any institution, organisation, entity or individual that could be relevant to the work of developing this/these guideline(s)?
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Yes
No
If yes, please specify and add to which guidelines it refers
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Section II - Intellectual conflict of interest, personal beliefs, previously published opinions
1. Have you published on a topic that expresses an opinion on the effectiveness of an intervention or currently performing research on a topic that could be affected by a recommendation of this guideline?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
2. Do you anticipate receiving clinical income from a recommendation of this/these guideline(s)?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
3. Are you involved with an advocacy group that may gain from this/these guideline(s)?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
4. Do you have strongly held beliefs, convictions or positions that may affect the subjectivity of your actions or decisions in the development of this/these guideline(s)?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
5. Currently or in the last 3 years, have you been involved in a leadership role in any research, project (not already reported above) relevant to the topic of this/these guideline(s), e.g., a research project funded by a nonprofit or governmental organisation?
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Yes
No
If yes, please specify and add to which guidelines it refers
*
6. Have you ever authored, coauthored, or publicly provided an opinion related to the topic of this/these guideline(s)? (e.g., a clinical practice guideline, textbook, review article, meeting poster or presentation, grand rounds talk, letter to the editor?)
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Yes
No
If yes, please specify and add to which guidelines it refers
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Section III - Confidentiality Agreement
The following principles must be followed by each member of an ESAIC Task Force.
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The information submitted in this form is true to the best of my knowledge and I confirm that I will declare and update any changes in interests until completion of this guideline.
I have read and I agree with the Confidentiality Agreement
I agree to keep all information and materials related to the ESAIC guideline development strictly confidential, and will not share or use them for personal orthird-party benefit.
I will securely store all documentation and information received as part of theguideline development project.
I understand that any breach of confidentiality may result in immediate removalfrom the working group and loss of authorship or future participationopportunities.
Signature:
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Submit Declaration
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