Diagnostic Imaging Pathways - Disclosure of Conflict of Interest

Disclosure of Conflict of Interest

Members of the Editorial Panel are required to complete and sign a 'Conflict Of Interest Disclosure Form'. Each member of the Editorial Panel is required to identify all relevant relationships within the last 2 years that may result in a conflict of interest. A relationship is deemed to be ‘relevant’ if there is reasonable potential for financial, professional, or other personal gain or loss for the individual, members of the individual’s household and/or employer, biasing the development, review and finalisation of materials including recommendations.

Conflict of Interest Disclosure Form

Each contributor to the content of Diagnostic Imaging Pathways is required to identify all relevant relationships within the last 2 years that may result in a conflict of interest.


A relationship is 'relevant' if there is reasonable potential for financial, professional, or other personal gain or loss for you, members of your household and/or your employer, biasing the development, review and finalisation of materials including recommendations. Such a conflict of interest will not necessarily preclude contributions.


Please insert brief explanatory information describing each 'relevant' relationship in the table.


'Relevant' relationships only

Yes

No

List each and describe briefly

>$10k or <$10k

FINANCIAL

Ownership interest. Do you or a household member have any ownership interests such as stock; stock options; partnership, membership, or other equity position in an entity regardless of the form of the entity, or any option or right to acquire an option; or any rights in any patent or other intellectual property?

Other. Do you or a household member receive or anticipate payment for any kind of service (e.g. clinical, speaking, advocacy, etc)?

Research grant. Are you or a household member an investigator or collaborator on a current or pending research grant?

Other research support. Do you or a household member receive other research support (any in-kind support)?

PROFESSIONAL

Consultant/advisory board. Do you or a household member have a consultancy and/or advisory board membership?

Expert witness. Have you or a household member served as an expert witness, consultant or otherwise provided a deposition, testimony or any other information to a government agency or for a legal proceeding, even if the case did not go to trial?

PERSONAL/OTHER

Other disclosures. Do you or a household member have any other 'relevant' relationships?

Employer. Do you know whether your employer has any 'relevant' financial or ownership relationships or interests?


Name: __________________________________________________


Signature: _____________________________________


Date: ______________


Download form as PDF


A register of Conflict of Interest Disclosure Forms is maintained by the Manager. The register alerts the Manager to the requirement to update disclosures every two years.