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. Faculty Disclosure of Conflict of Interest Name * Department * - Select - Department of Anesthesiology Department of Biochemistry, Microbiology and Immunology Department of Cellular and Molecular Medicine Department of Emergency Medicine Department of Family Medicine Department of Innovation in Medical Education Department of Medicine Department of Obstetrics and Gynecology Department of Ophthalmology Department of Otolaryngology - Head Neck surgery Department of Pediatrics Department of Pathology and Laboratory medicine Department of Psychiatry Department of Diagnostic Radiology Department of Surgery School of Epidemiology, Public Health and Preventive Medicine Division * - Select - Not applicable Division of Cardiology Division of Clinical Epidemiology Division of Critical Care Division of Clinical Hematology Division of Dermatology Division of Endocrinology and Metabolism Division of Gastroenterology Division of Internal Medicine Division of Geriatrics Division of Infectious Diseases Division of Medical Oncology Division of Nephrology Division of Neurology Division of Nuclear Medicine Division of Palliative Care Division of Rehabilitation Division of Respirology Division of Rheumatology Division * - Select - Not Applicable Division of Maternal Fetal Medicine Division of Gynecologic Oncology Division of General Obstetrics and Gynecology Division of Reproductive Medicine Division of Urogynecology and Pelvic Reconstructive Surgery Division * - Select - Not Applicable Division of Addictions Division of Child and Adolescent Psychiatry Division of Forensic Psychiatry Division of Geriatric Psychiatry Division * - Select - Not Applicable Division of Radiation Oncology Division * - Select - Not Applicable Division of Cardiac Surgery Division of General Surgery Division of Orthopedic Surgery Division of Neurosurgery Division of Thoracic Surgery Division of Urology Division of Vascular Surgery Division of Plastic Surgery Telephone No. * Email Address * Please select one of the following three options: * I do not have any affiliation (financial or otherwise) with a pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry that could be perceived as a direct/indirect conflict of interest as defined in policy interactions between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supply Industries. I have/had an affiliation (financial or otherwise) with a pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry that could be perceived as a direct/indirect conflict of interest as defined in policy Interactions Between the Faculty of Medicine and the Pharmaceutical, Biotechnology, Medical Device, and Hospital and Research Equipment and Supply Industries. (Please complete the section below indicating the commercial organization(s) with which you have/had affiliations, and briefly explain the relationship you have with the organization. I have completed a Conflict of Interest Disclosure form at my place of work. I give consent to the Faculty of Medicine University of Ottawa to access this information. If you selected Option B, please answer questions 1-9 1. I am a member of the advisory board (or equivalent) of a commercial entity. Yes No 2. I am a member of a Speaker’s Bureau. Yes No 3. I have received any payment(s) or honorarium(a) from a commercial entity in the pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry (i.e. for speaking, consultation, participation in meetings, executive position, gifts, etc.). Yes No 4. I have received a grant(s) from a commercial entity. Yes No 5. I hold a patent for a product marketed by a commercial entity. Yes No 6. I hold investments (excluding diversified mutual funds and managed funds) in a commercial entity in the pharmaceutical, biotechnology, medical device, hospital or research equipment/supply industry. Yes No 7. I am currently participating in, or have participated in, an industry sponsored clinical trial within the last two years. Yes No 8. I hold individual or joint ownership in a commercial entity, which I acquired by purchase or through the provision of services. Yes No 9. I conduct or supervise research not otherwise disclosed in this form that could affect the value of a technology I developed (i.e. compound, drug, device, diagnostic, medical or surgical procedure). Yes No Certification * I certify that the information that I have provided is true and that all of my significant relationships with industry have been disclosed. I understand that this disclosure must be updated on a yearly basis.