IUGA - Reporting for Conflicts of Interest

IUGA Leadership and Management Disclosure Declaration Form

The IUGA must insure balance, independence, objectivity, and scientific rigor in all its activities. We require all individuals in a position to influence the direction of the association to fill out the disclosure form below prior to the appointment to a leadership position within IUGA. In order to ensure that our activities promote improvements or quality in healthcare and not a specific proprietary business interest or a commercial interest, we need to identify all conflicts of interest.

Individuals are required to disclose all relevant financial and intellectual relationships with commercial interests (entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) or other medical associations in any amount as well as the nature of the relationship within the past 24 months.

Declaration of a conflict of interest does not necessarily preclude serving in a leadership role within IUGA. However, based on this disclosure information, IUGA may disqualify any individual from planning, implementation and participation if a conflict of interest that may contribute to commercial bias is determined to exist and cannot be resolved. Therefore, a full and honest disclosure is encouraged. In accordance with the conflict of interest policy of IUGA, the undersigned confirms that all information below is complete and truthful.

Please fill out all fields and answer all the questions below prior to submitting this form.

Personal Details

First name*

Last name*

Organization

Country*

E-mail*

Committee name

Specify Other*

Conflict of Interest Read COI Policy

Do you have any relevant financial or intellectual relationships with commercial interests (entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients) or other medical associations in any amount within the past 24 months?

Yes

Please list the commercial entities with the type of relationship listed below.

Grant / Research support

Consultant / Advisor

Speakers bureau

Patent holder

Member of the following scientific advisory board(s)

Member of board of directors for the following organization(s)

Employee

Stock Shareholder (directly purchased)

Editor, editorial board member or other publishing position (other than author or reviewer) with medical publishing company or medical journal (other than the International Urogynecology Journal)

Other Financial Support

Other Relationship/Affiliation (specify)

Will your position include the opportunity to promote or influence others to use specific products/services of the commercial entities or medical association(s) you've listed above?

Yes

Signature

I have read and agree to the contents of the conflict of interest policy document of the IUGA.

I understand that I will be required to submit this COI disclosure form initially and every year as long as I serve in a leadership function.

The information I have provided is true and complete to the best of my knowledge and I accept responsibility for the accuracy of the information above.

Signed: *

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