NATIONAL CLINICAL GUIDELINES: MATERNITY & GYNAECOLOGY 2022

 We are asking you to complete this form and declare conflicts of interest relevant to the
Guideline Programme as well as to the National Clinical Guideline ___________________
 The declaration should cover all current interests and any from the last five years.
 Please also declare any new interests that are not currently held, but will arise during
involvement with the Guideline Programme
 Interests that are not relevant to the Guideline Programme do not need to be declared.
 If you are unsure about whether an interest/activity is a conflict of interest, please contact
Professor Keelin O’Donoghue (k.odonoghue@ucc.ie )to discuss or disclose the interest/activity

Section 1: Do you have any direct interests to declare?

In this section, we ask about your own direct interests. These can be financial (a financial interest)
or non-financial (a non- financial personal or professional interest). Section 2 asks about any
interests of people and organisations you have a close association with; these are indirect interests.

FINANCIAL INTERESTS

This relates to any financial benefits to you (direct interests), that could be seen as relevant to the
Guideline Programme. This means anything of monetary value, including:- payments for services;
equity interests, including stocks, stock options, shareholdings or other ownership interests; and
intellectual property rights, including patents and copyrights and royalties arising from such
interests. This includes payments for speaking engagements and sitting on advisory boards, and
clinicians undertaking private practice, as well as personal payment from the commercial sector to
undertake research or attend conferences.

Please give details of any FINANCIAL INTERESTS that could be seen as relevant to the Guideline
Programme, (or state ‘nil’ if none to declare)

Details of interest Date arose Date ceased

NON-FINANCIAL PROFESSIONAL AND PERSONAL INTERESTS

This relates to any non-financial professional or personal benefit, or non-financial issue that could
affect your perceived objectivity. This includes being an advocate for a particular group or a
member of a lobbying group or holding a position of authority in a professional organisation,
university, charity, or advocacy group. This also means being actively involved in a research project
related to the guideline in question or publishing work or opinions pieces on the subject matter.

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NATIONAL CLINICAL GUIDELINES: MATERNITY & GYNAECOLOGY 2022

Please give details of any NON-FINANCIAL PROFESSIONAL AND PERSONAL INTERESTS that could
be relevant to the Guideline Programme, (or state ‘nil’ if none to declare)

Details of interest Date arose Date ceased

Section 2: Interests of people and organisations you are closely associated with

INDIRECT INTERESTS

In this section we ask about circumstances where there is, or could be perceived to be, an
opportunity for a third party closely associated with you to benefit. Indirect interests can arise from
close relatives, friends or associates as well as from employers, and include scenarios where you
are participating in guideline development representing a particular organisation.

Please give details of any INDIRECT INTERESTS that could be relevant to the Guideline
Programme (or state ‘nil’ if none to declare)

Details of interest Date arose Date ceased

Declaration

I confirm that the information provided above is complete and correct. I acknowledge that any
changes in these declarations during my work with the Guideline Programme must be notified to
the Guideline Programme Team as soon as the interest arises.

Full name: Enter text here.

Signed: Enter text here. Date: Enter text here.

Note: Electronic signatures are accepted, or the document can be printed, signed and scanned.

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