Declaration of interest

Name:
Place of main employment (name of hospital, university, company, agency or any other institute or organisation):
City:
Country:
Biography:
Are you (or your next of kin) performing or have been performing for the past two years any paid or unpaid consultancy work for any commercial or non-commercial organization (e.g. pharma company, hospital, national or international body, pressure group etc.) that is active in the fields related or relevant to the activities of ESHRE.

Do you (or your next of kin) hold or have been holding for the past two years an editorship in field-related international journals?

Next to your main employment, are you (or your next of kin) employed or have been employed for the past two years by any commercial company or non-commercial organization that is active in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) receive or have been receiving for the past two years any personal financial reimbursements for travel/hotel expenses from commercial companies or non-commercial organizations active in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) receive or have been receiving any grants from commercial companies or non-commercial organizations active in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) hold or have been holding for the past two years (a) national or international political mandate(s)?

Are you (or your next of kin) or have you (or your next of kin) been for the past two years an officer or board member in any society or organisation active in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) participate or have been participating in the past two years in sponsored trials (personal or institutional) in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) hold or have been holding for the past two years (a) patent(s) – existing or pending - in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) have or have had for the past two years any other commercial interest such as personal shares, royalties, stock options or other ownership interests in commercial companies active in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) receive or have been receiving for the past two years any payments for commissioned papers for publication (in any format) in journals in the fields related or relevant to the activities of ESHRE?

Do you (or your next of kin) receive or have been receiving for the past two years any payments for attending meetings in the fields related or relevant to the activities of ESHRE?

Are there any other activities in the fields related or relevant to the activities of ESHRE that you (or your next of kin) engage in or have been engaged in for the past two years and that you think may constitute a potential conflict of interest?

14) Have you experienced a potential conflict of interest with a previous employer towards financial aspects?