DOI - Disclosure of Interest

Form for Disclosure of Interest (DoI)

First name *

Surname *

Email *

Affiliation *

Country *

Telephone number

1. Tick this option if you are employed (or if you have been employed in the last two years) in a concerned commercial entity.

By “concerned” we mean “concerned with radiation protection, radiation production and dosimetry”.

Commercial entity

Please indicate name, location and nature of the commercial entity.

Role

Please indicate your position in the commercial entity (Governance, SEO, employee, advisory, ...)

From/to (month/year)

Please specify the relevant period of time each activity took place in (month/year).

Area of activity

Please indicate the subject matter of the activity such as types of substances, products, guidance documents, processes or policies.

2. Tick this option if you are a current member (or if you have been a member in the last two years) of an occasional consultancy/business advice to a concerned commercial entity.

By “concerned” we mean “concerned with radiation protection, radiation production and dosimetry”.

Commercial entity

Please indicate name, location and nature of the commercial entity.

Role

Please describe your consultancy role.

From/to (month/year)

Please specify the relevant period of time each activity took place in (month/year).

Area of activity

Please indicate the subject matter of the activity such as types of substances, products, guidance documents, processes or policies.

3. Tick this option if you have any intellectual property right (IPR) (including patents, trademarks, know-how and/or copyrights) related to a product owned by you or of which you are directly a beneficiary.

Name of the product

Please indicate the name of the product.

Type of IPR

Please describe the type of IPR (including patents, trademarks, know-how and/or copyrights).

Area of activity/subject of matter

Please indicate the subject matter of the activity such as types of substances, products, guidance documents, processes or policies.

4. Tick this option if you currently receive (or have received in the last two years) a support to your own research activities from a concerned commercial entity.

By “concerned” we mean “concerned with radiation protection, radiation production and dosimetry”.

Commercial entity

Please indicate name, location and nature of the commercial entity.

Role

Please describe your role in the research activity (PI, collaborator, …)

From/to (month/year)

Please specify the relevant period of time each activity took place in (month/year).

Area of activity

Please indicate the subject matter of the activity such as types of substances, products, guidance documents, processes or policies.

5. Tick this option if you are receiving (or have received in the last two years) a support to any of your own activities from a funding received by the organisation/institution to which you belong from a concerned commercial entity.

By “concerned” we mean “concerned with radiation protection, radiation production and dosimetry”.

Commercial entity

Please indicate name, location and nature of the commercial entity.

From/to (month/year)

2. Please specify the relevant period of time each activity took place in (month/year).

Area of activity

Please indicate the subject matter of the concerned commercial activity such as types of substances, products, guidance documents, processes or policies.

6. Tick this option if you are currently receiving (or have received in the last two years) a support to your own activities from a concerned commercial or service activity carried out by the institution you belong to.

Commercial/service activity

Please describe the commercial or service activity which is carried out by the institution you belong to.

From/to (month/year)

Please specify the relevant period of time each activity took place in (month/year).

7. Tick this option if you have nothing to declare and none of the options above can be applied.

8. Any other fact of relevance or additional comments.

Please comment here

I agree that the information provided by me can be used by EURADOS for three years in order to allow EURADOS to be compliant with its Code for the management of the conflict of interest.

All data will be removed as soon as I will no longer be in the position for which I need to disclosure my interest. For any further issues regarding your personal data, see the Data Privacy Statement.

With my signature, I agree to the above statement and to the Data Privacy Statement, which I have read.

Signature *

Please sign above

Form for Disclosure of Interest (DoI)

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