Confidential Disclosure of Conflict of Interest Form

The University of Ottawa’s Faculty of Medicine requires that all faculty members and staff complete this Disclosure of Conflict of Interest form annually. The 2010 Faculty of Medicine’s policy on “Interactions between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supplies Industries”, Section 33 states:

On an annual basis, faculty members and staff will disclose, in writing, relationships with Industry to the Faculty of Medicine's Faculty Affairs. Disclosures will be reviewed and if a significant unmanaged conflict of interest is identified, then the disclosure will be forwarded to Department heads or supervisors. The written disclosure must specify nature of the relationship with Industry, the work performed, and total amount and type of compensation or other benefit received. Similarly, faculty members and staff will verify annually that their reporting was accurate and complete.  Management of unresolved conflicts of interest will be done in collaboration between the faculty member, the Faculty Affairs' Conflict of Interest Resolution Committee, the Department head and/or supervisor.

This form acts as a document that will be reviewed by the Faculty's Faculty Affairs and if warranted, will be reviewed with the Faculty member's Department/Divisional Chief.

For the purposes of this disclosure, Conflict of Interest (COI) is defined as:

Conflict of Interest (COI) may be actual, potential or perceived. A conflict of interest occurs when an individual has a significant financial, professional or other personal consideration with Industry that may compromise, or have the potential to compromise or the appearance of compromising, their professional judgment or integrity in clinical responsibilities, teaching, conducting or reporting research, or performing other obligations.