SIGN 50: A guideline developer's handbook - Annex A: Register of interests

Annex A: Register of interests - Fictitious example

Having read the attached SIGN Policy on Declaration of Competing Interests I declare the following competing interests for the previous year, and the following year. I understand that this declaration will be retained by the SIGN Administrator for 5 years, and made available for public inspection at the SIGN Office.

Signature:
Name:	Lindsay Brown
Relationship to SIGN:	Member of the Guideline Development Group on Bronchiolitis
Personal interests
This section relates to interests of the person concerned. For their partners or close relatives, interests are restricted to employment in, or share holdings in, healthcare organisations. Specific interests are those which relate to a topic or remit of the particular guideline. Non specific interests are those which are otherwise relevant to the work of SIGN.
Remuneration from employment
	Name of Employer and Post held	Nature of Business	Self or partner / relative	SPECIFIC?
Details of Employment held which may be significant to, or relevant to, or bear upon the work of SIGN	Consultant Bogside NHS Trust Sales Representative for Ultra (antiviral drug) Aviemore Pharmaceuticals PLC	Medical Practitioner Manufacture of antiviral drugs used in paediatric conditions	Self Partner	No yes
Remuneration from self-employment
	Name of Business	Nature of Business	Self or partner / relative	SPECIFIC?
Details of self-employment held which may be significant to, or relevant to, or bear upon the work of SIGN	Bogside Physiotherapy Practice	Private physiotherapy practice	Daughter	yes
Remuneration as holder of paid office
	Nature of Office held	Organisation	Self or partner / relative	SPECIFIC?
Details of office held which may be significant to, or relevant to, or bear upon the work of SIGN	Organist, St Elsewhere’s Church	Church of St Elsewhere	Self	No
Remuneration as a director of an undertaking
	Name of Undertaking	Nature of Business	Self or partner / relative	SPECIFIC?
Details of directorship held which may be significant to, or relevant to, or bear upon the work of SIGN	Bogside Private Hospice	Non executive Director	Self	No
Remuneration as a partner in a firm
	Name of Partnership	Nature of Business	Self or partner / relative	SPECIFIC?
Details of Partnership held which may be significant to, or relevant to, or bear upon the work of SIGN	Bogside Computer Games Ltd	Software development	Brother	No
Shares and securities
	Description of organisation	Description of nature of holding (value need not be disclosed)	Self or partner / relative	SPECIFIC?
Details of interests in shares and securities in commercial healthcare companies, organisations and undertakings	Mega oxygen Supplies PLC Glastonbury Pharmaceuticals PLC	Shares Shares	Self Partner	yes No
Remuneration from consultancy or other fee paid work commissioned by, or gifts or support from, commercial healthcare companies, organisations and undertakings
	Nature of work	For whom undertaken and frequency	Self or partner / relative	SPECIFIC?
Details of consultancy or other fee paid work which may be significant to, or relevant to, or bear upon the work of SIGN	Consultancy Lecturing on terminal care	Ozone Inc (manufacturer of ventilators) 2 days / year Lecture fee paid by Exit Inc. (once only)	Self Self	yes No
Details of gifts which may be significant to, or relevant to, or bear upon the work of SIGN	Personal computer	Exit Inc.	Self	No
Details of support to attend meetings / conferences which may be significant to, or relevant to, or bear upon the work of SIGN	Travel and conference fees to attend annual paediatric respiratory forums	Ozone Inc	Self	yes
Non-financial interests
	Description of interest	Self or partner / relative	SPECIFIC?
Details of nonfinancial interests which may be significant to, or relevant to, or bear upon the work of SIGN	Member of Bronchosupport, Bogside (charitable support group)	Self	yes
Non personal interests
This section relates to support from healthcare companies to departmental / employer / business for research and audit activities, travel and subsistence for conferences, etc.
	Name of company, organisation or undertaking	Nature of interest	Self or partner / relative	SPECIFIC?
Details of non-personal support from commercial healthcare companies, organisations or undertakings.	Universal Pharmaceuticals PLC Nairn Pharmaceutics PLC	Departmental support for research nurse (2 sessions / week) performing clinical trials of physiotherapy in bronchiolitis Departmental support for Registrar’s travel to meeting of European Society of Palliative Care (Self, non specific)	Self Self	Specific Non specific
Date received at SIGN