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Disclosure of conflict of interest from : ……………………………………….. Consulting activities , governance functions , writi

Disclosure of conflict of interest from : ……………………………………….. Consulting activities , governance functions , writing of reports: No / Yes * Company ( ies ): …………………………………… Clinical test, other works , communication about promotion:

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Disclosure of conflict of interest from : ……………………………………….. Consulting activities , governance functions , writi

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  1. Disclosure of conflictof interest from: ……………………………………….. • Consulting activities, governancefunctions, writing of reports: • No / Yes* Company(ies): …………………………………… • Clinical test, otherworks, communication about promotion: • No / Yes * Company(ies): …………………………………… • Financial interest (shareholder): • No / Yes * Company(ies): …………………………………… • Link withpersonshavingfinancialinterest or involved in the governance: • No / Yes * Company(ies): …………………………………… • Reception of donations by an association that I amin charge of: • No / Yes * Company(ies): …………………………………… • Reception of fundsfrom an association I am in charge of and which has received a donation: • No / Yes * Company(ies): …………………………………… •  Holder of a patent, editor of a workused by the industry: • No / Yes * Company(ies): …………………………………… • * Delete the non applicable option

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