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Disclosure Form for Potential Conflicts Of Interest

Instructions
The purpose of this form is to provide SGN/SSN with information about your other interests that could influence your position within the SGN/SSN Board, within your Commission or Working Group.

Relevant financial activities
Please report all sources of revenue that accrued either directly to you, to your family, or were paid to your institution on your behalf for the last 3 years with re-evaluation every year.  

This should include all monies from sources with relevance to your work. If there is any question, it is usually better to disclose a relationship than not do so. Please note that your interactions with the works’ sponsor outside the submitted work should be listed here.

The goal is to provide information for the SGN/SSN about your interaction with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing your position in the SGN/SSN. For grants you have received for work outside the SGN/SSN you should disclose support only from entities that could be perceived to benefit financially from your position, such as drug companies, or foundations supported by entities that could be perceived to have a financial stake in your decision.

Identifying information
Companies and possible conflicts
Please list anything else, not listed above, which could generate a conflict of interest:
Further information

If the SGN/SSN Board needs further information on one or more of the above mentioned points I am willing to disclose them at any time.

I agree that my form is disclosed to the Board members, to the presidents and members of the commissions and working groups of the SSN-SGN.