EuroQol Declaration of Interests

Step 1 of 9

Introduction

The EuroQol Research Foundation governs intellectual property rights, including the EQ-5D family of instruments, and is supported by the EuroQol Group Association. Members of the EuroQol Group collectively own the EuroQol instruments.

Members of the EuroQol Group actively support the work of the Foundation through their involvement in research and development related to EuroQol agendas. Members also support the Group by standing for election to the Board, Executive, or other committees within the organisation.

All actual, potential, or perceived conflicts of interest must be disclosed and managed in accordance with the declaration of interest policy. Please complete the declaration below and review your answers before the final submission.

What to expect

You will complete Sections A to F and then review everything before submission.
The final submission stores the declaration with the EuroQol office and emails a copy to communications@euroqol.org.
The person filling out the form will also receive a copy of the submission by email.

I confirm that I have read and understood the declaration information above.

Step 2 of 9

Section A: Personal Information and Current Roles

Please provide your contact details and select all current roles that apply within the EuroQol Group and/or EuroQol Research Foundation.

Name and Surname

Alias (Optional)

Email Address

Current Roles

Select all that apply. At least one role will be required in the final validation pass.

EuroQol Member Member of the DSWG, PHS, VWG or YPWG Member of the Communications, Media and/or Education and Outreach Team Member of the VMC Member of the Executive Committee Member of the Board EuroQol Office Employee

Step 3 of 9

Section B: Personal Appointments

Please declare all personal appointments including salaried, consulting, honorary and fiduciary positions. Enter each appointment as a separate entry.

Appointment 1

Institution, Company or Organisation

Role

Salaried or Consulting Position Honorary Position Fiduciary Position Actual or Potential Conflict

Step 4 of 9

Section C: Declaration of Intellectual Property

Please declare all intellectual property held by you personally, through affiliation or appointment, that has an actual or potential conflict with the EuroQol Foundation and/or Association.

I have read Section C and have no potential or actual conflicts to declare.

Intellectual Property Entry 1

IP Description

IP Type

IP Owner

Country of Registration

Actual or Potential Conflict

Step 5 of 9

Section D: Decision-Making Bodies

Please declare all positions held within decision-making bodies where there is actual or potential overlap of advisory roles and/or interpretation of health data.

I have read Section D and have no potential or actual conflicts to declare.

Decision-Making Body Entry 1

Decision-Making Body

Specify

IP Owner

Country of Registration

Actual or Potential Conflict

Step 6 of 9

Section E: Family Holdings and Appointments

Please list all relevant interests of immediate family members that are considered an actual or potential conflict with EuroQol.

I have read Section E and have no potential or actual conflicts to declare.

Family Entry 1

Relationship to Immediate Family Member

Institution, Company or Organisation

Fiduciary or Other Position

Actual or Potential Conflict

Step 7 of 9

Section F: Other Interests

List any other relationships or interests which may potentially conflict, or be perceived to conflict, with your role at the EuroQol Group and/or EuroQol Research Foundation.

I have read Section F and have no potential or actual conflicts to declare.

Other Interest Entry 1

Actual or Potential Conflict

Description

Step 8 of 9

Review Your Declaration

Review the information below before moving to the final confirmation step. Use Edit to jump back to a section without clearing your answers.

Introduction

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Section A: Personal Information and Current Roles

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Section B: Personal Appointments

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Section C: Declaration of Intellectual Property

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Section D: Decision-Making Bodies

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Section E: Family Holdings and Appointments

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Section F: Other Interests

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Step 9 of 9

Confirmation

You are at the final step. Confirm your declaration details below. Submitting this form will save the declaration in WordPress and email a copy to the configured recipient.

Before final submission

Your signed name should match the declaration you intend to submit.
The final submit button stores the declaration with the EuroQol office, emails a copy to communications@euroqol.org, and sends a copy to the person completing the form.

Signed Name

I declare that the information provided in this declaration is complete and accurate to the best of my knowledge.