PUBLIC DECLARATION OF INTERESTS

Last name	Function	

		
First name	Speciality	
		
Institution, company, organization		
Professional address
		
Additional professional address or
personal address 		
Phone number		
Fax number		
Email address		

do hereby declare on my honour that, to the best of my knowledge, the only direct or indirect interests I have with companies* whose products or articles come under the scope of Afssaps**, with professional organisations or council organisations involved in these sectors, are those listed below***.

1.	Financial interests in a company (FI)	  Nil	
-	Currently
-	To your knowledge : you, your spouse, minor child
-	Any financial interest : quoted or unquoted securities, whether it concerns shares, bonds or other financial assets in capital resources ; interests in a company of the concerned sector, one of its subsidiary or a corporation whose the company owns a part of the capital must be declared to the extent of your immediate and expected knowledge. You are required to provide the name of the company, the type and the quantity of the securities or the percentage of the fraction of owned capital. 
(Investment funds or collective products - whose the person controls neither the management, nor the composition – are excluded from the declaration)		
Company
(corporation, institution, organisation)	Type of investment
(market value, owner’s equity or bonds)		< 5000 € or < 5% of the capital	≥ 5000 € or ≥ 5% of the capital	Start date	End date	

							

2.	

Personal activities

Research, scientific assessment or council activities, delivered for concerned companies or not, must be declared in these categories. In case these activities regard a specific product, you will have to state the following information besides the name of the company: the name of the product or medical device (common designation (active principle) or name of the speciality (trade name)), the framework and the subject of the activity ; the start date and the foreseeable duration of activity.	
2.1.   Permanent links (PL)	
2.1.1.     Owner, manager, partner, employee, participation in a company’s decision body  

-	Currently, in negociation or in the previous 5 years
-	Companies* whose products or articles fall under the scope of Afssaps, professional organisations or council organisations involved in these sectors are concerned 
-	People appointed in commissions representing private interests (ex. Pharmaceutical industry unions) state the name of the belonging organization in this category and the name of their employer if need be. 
	    Nil	
Company (corporation, institution, organization)	Position in the company	Nature of contract	Employ date or start date of negociations 	End date	

					

					
2.1.2	.     Other regular activities
-	Currently or in the previous 5 years
-	Individual consulting, member of an experts group or equivalent.…, for a company whose products or articles fall under the scope of Afssaps, for professional organisations or council organisations involved in these sectors 
	    Nil

Company (corporation, institution, organisation)	Nature of activity / Subject / Name of product	
Earnings
	Start date	End date	
		 None
 You
 Institution
 You/Institution			
		 None
 You
 Institution
 You/Institution			
2.2.   Occasional interventions : clinical, preclinical trials and scientific works (OI-CT)
Activities aimed at this category are the participations in carrying out non clinical and preclinical trials (methodological, analytical trials, chemical, pharmaceutical, biological, pharmacological or toxicological trials…), clinical trials and epidemiological studies, observation studies on practices and prescriptions… 
In the present document, people participating in carrying out clinical studies are named investigator (principal investigator for a monocentric survey and coordinator investigator for a multicentric survey); people participating in non clinical or preclinical studies are named experimenter.	
2.2.1.	As a principal investigator of a monocentric survey, coordinator investigator or principal experimenter
-	Currently or in the previous 5 years
-	Participations in carrying out non clinical and preclinical trials and surveys (methodological surveys, analytical trials, chemical, pharmaceutical, biological, pharmacological or toxicological trials…), clinical surveys and epidemiological surveys, observation surveys on practices and prescriptions…
	    Nil	
Company (corporation, institution, organisation)	Nature of activities / Name of product	Your position 
(principal investigator, coordinator investigator,  principal experimenter…)	Start date	End date	

					
2.2.2.	 As a co-investigator, non-principal experimenter, contributor to surveys
-	Currently or in the previous 3 years
-	Participations in carrying out non clinical and preclinical trials (methodological, analytical trials, chemical, pharmaceutical, biological, pharmacological or toxicological trials…), clinical trials and epidemiological surveys, observation studies on practices and prescriptions…

	    Nil	
Company (corporation, institution, organisation)	Nature of activities / Name of product	Your position 
(co-investigator, non-principal experimenter, contributor to surveys…)	Start date	End date	

2.3.   Occasional interventions : expert-reports (OI-ER)	
2.3.1.      Expert-reports carried out with a view to appear in a file subject to Afssaps assessment   
                                                                                               
-	Currently or in the previous 5 years
-	To the best of your knowledge, insofar as you are expected to be informed about it : in other cases, please fill in the following category 2.3.2.
	    Nil	
Company (corporation, institution, organisation)	Framework of expert-report / Subject / Name of product	Earnings 	Start date	End date	

		 None
 You
 Institution
 You/Institution			
		 None
 You
 Institution
 You/Institution			
2.3.2	.    Other expert-reports  

-	Currently or in the previous 3 years

    Nil	
Company (corporation, institution, organisation)	Framework of expert-report / Subject / Name of product	Earnings	Start date	End date	

	

	 None
 You
 Institution
 You/Institution			

		 None
 You
 Institution
 You/Institution			

		 None
 You
 Institution
 You/Institution			

2. 4.   Occasional interventions : consultant activities (OI-CA)  

-	Currently or in the previous 3 years
-	Occasional consultant, participation in a working group, think tank, audit activities within the framework of a professional accreditation organisation…
	     Nil	
Company (corporation, institution, organisation)	Nature of service or subject /  Name of product	Earnings	Start date	End date	

		 None
 You
 Institution
 You/Institution			

		 None
 You
 Institution
 You/Institution			
2.5	. Occasional interventions : congress, seminars, conferences, other meetings
1.5	(IO-CF)
-	Meetings supported or organized by a company that manufactures or markets health products
	
2.5.1.     Invitations as a speaker 
-	Currently or in the previous 3 years

   Nil	
Company
	Location and title of meeting / Subject of presentation / Name of product	Earnings	Date	
		 None
 You
 Institution
 You/Institution		
		 None
 You
 Institution
 You/Institution		
2.5.2.	Invitations as a member of the audience (travel and accommodation expenses paid by the company)  

-       Currently or in the previous year
 	   Nil	
Company	Location and title of meeting / Subject of presentation / Name of product	Date	

2.6   Occasional interventions : other (OI-OTH) 
-	The nature of the link is different from those listed above
-	Owner of a patent or inventor of a product, procedure or any other kind of intellectual property ;  party or witness in a procedure relative to a health product	   Nil	
Company (corporation, institution, organisation)	Nature of activity / Name of product	Start date	End date	

				

				

	

3.	SIGNIFICANT FINANCIAL CONTRIBUTIONS TO THE BUDGET OF AN ORGANISATION YOU ARE IN CHARGE OF (BC)
-	Currently or in the previous 3 years           
-	This category concerns people in charge of a research organisation, institute, department, service, research association or patients association
-	You are not required to declare financings whose amount contribute to a small part of the operating budget of your structure (< 15%  or equivalent for example) ; the amount is annually assessed, from a common source ; contributions can be subsidies for surveys or researches, grants or sponsorships, payments in kind or in cash, equipments, training taxes, other… 
	
  Nil	
Company (corporation, institution, organisation)	
Object of contribution
	Beneficiary institution	Start date	End date	

					

					

					

4.	SALARIED RELATIVES IN COMPANIES LISTED ABOVED (REL)
-	Currently
-	Spouse – husband / wife or person living at the same address  -  ascendants or descendants, immediate collaterals including their spouse… 
(The names of family members do not have to be mentioned) 
	    Nil

Company (corporation, institution, organisation)	Function and position in the company (please specify, if need be, if it is a manager position and/or whose activity is in connection with a product)	Family relationship
(spouse, child, brother, sister, father, mother, father-in-law, mother-in-law, brother-in-law, sister-in-law)
	Start date	    End date	

	
5.	OTHER

-	Other facts or interests that could be considered as prejudicial to your impartiality
-	Expert works in other bodies / institutions in connection with a health product
-	Other facts that should be, in your opinion, communicated to the Agency and to the general public
	
    Nil

Company (if need be)	Nature of activity	Comment	Start date	   End date	

					

					

I the undersigned,_____________________________________________________________, bind myself, in case of change of the links listed above or acquisition of additional interests that must be communicated to the Agency, to inform it and to fill in a new public declaration of interests*.
This declaration does not clear me to declare any potential conflict of interests at the beginning of every expert activity I participate in. 

Location : ----------------------------------------------------------------

Date : -----------------------------------

Signature

Collected information are computerized. In compliance with enactments of the modified law n°78-17, 6 January 1978, relative to computer science, files and freedom, you have the right to access and correction of data that concern you.