Notice regarding documents for applying as subject experts in various panels of CDSCO

ANNEXURE-A DECLARATION OF INTERESTS FOR EXPERTS FOR CDSCO CDSCO work on drug regulatory issues requires the assistance of external experts who may have interests related to their expertise. To ensure the highest integrity and public confidence in its activities, CDSCO requires that experts serving in an advisory role disclose any circumstances that could give rise to a potential conflict of interest related to the subject of the activity in which they will be involved. Please complete this form and submit it to CDSCO (HQ) If you are unable or unwilling to disclose the details of an interest that may pose a real or perceived conflict, you must disclose that a conflict of interest may exist and the CDSCO may decide that you be totally recused from the meeting or work concerned, after consulting with you. Name of expert: Institution: Email: Contact No:- Please answer each of the questions below. If the answer to any of the questions is "Yes", briefly describe the circumstances on the last page of the form. 1. EMPLOYMENT AND CONSULTING Within the past 2 years, have you received remuneration from a commercial entity or other organization with an interest related to the subject of the meeting of work? I a Employment Yes No I b Consulting, including service as a technical or other advisor Yes No 2. RESEARCH SUPPORT Within the past 2 years, have you or has your research unit received support from a commercial entity or other organization with an interest related to the subject of the meeting or work?2a Research support, including grants, collaborations, sponsorships, and other funding Yes No 2b Non-monetary support valued at more than Rs. 20,000/- overall (include equipment, facilities, research assistants, paid travel to meetings, etc.) Yes No Support (including honoraria) for being on a speakers bureau, giving speeches or training for a commercial entity or other organization with an interest related to the subject of the meeting or work? 3. INVESTMENT INTERESTS Do you have current investments (valued at more than Rs. 200000/- overall) in a commercial entity with an interest related to the subject of the meeting or work? Please also include indirect investments such as a trust or holding company. You may exclude mutual funds, pension funds or similar investments that are broadly diversified and on which you exercise no control. 3a Stocks, bonds, stock options, other securities (e.g., short sales) Yes No 3b Commercial business interests (e.g., proprietorships, partnerships, joint ventures, board memberships, controlling interest in a company) Yes No 4. PUBLIC STATEMENTS AND POSITIONS (during the past 2 years) 4a As part of a regulatory, legislative or judicial process, have you provided an expert opinion or testimony, related to the subject of the meeting or work, for a commercial entity or other organization? Yes No 5. ADDITIONAL INFORMATION 5a If not already disclosed above, have you worked for the competitor of a product that is the subject of the meeting or work, or will your participation in the meeting or work enable you to obtain access to a competitor's confidential proprietary information, or create for you a personal, professional, financial or business competitive advantage? Yes No5b To your knowledge, would the outcome of the meeting or work benefit adversely affect interests of others with whom you have substantial common personal, professional, financial or business interests (such as your adult children or siblings, close professional colleagues, administrative unit or department)? Yes No 5d Have your received any payments (other then for travel costs) or honoraria for speaking publicly on the subject of this meeting or work? Yes No 5e Is there any other aspect of your background or present circumstances not addressed above that might be perceived as affecting your objectivity or independence? Yes No Within the past 4 years, have you had employment or received research support or other funding from or had any other professional relationship with, an entity directly involved in the production, manufacture, distribution or sale of tobacco products or representing the interests of any such entity? Yes No EXPLANATION OF "YES" RESPONSES: if the answer to any above questions is “yes”, check above and briefly describe the circumstances on this page. Nos. I - 3 Name of Belongs to Amount of Current Type of interest, company, you, a family income or Interest (or question organization, member value of year number and or employer, interest is ceased) category and institution research unit assumed to basic descriptive or other? be details. significant) Nos.4-5: Describe the subject, specific circumstances, parties involved, time frame and other relevant detailsCONSENT TO DISCLOSURE. By completing and signing this form, you consent to the disclosure of any relevant conflicts to other meeting participants and in the resulting report or work product DECLARATION: I hereby declare on my honor that the disclosed information is true and complete to the best of my knowledge. Should there be any change to the above information, I will promptly notify to CDSCO and complete a new declaration of interest form that describes the changes. This includes any change that occurs before or during the meeting or work itself and through the period up to the publication of the Final results or completion of the activity concerned . Date: _________________ Signature________________________CURRICULUM VITAE NAME: DATE OF BIRTH: MARITAL STATUS: CONTACT DETAILS: ACADEMIC DETAILS/ QUALIFICATION: Sr. No. COURSE INSTITUTION UNIVERSITY/ YEAR OF GRADE / % BOARD PASSING OF MARKS OBTAINED AREAS OF SPECIALISATION: DETAILS OF PRESENT AND PREVIOUS POSITIONS:PROFESSIONAL EXPERIENCE: Sr. No. POST DURATION INSTITUTION/ COMAPNY ACHIEVEMENTS: SCIENTIFIC PUBLICATIONS AND PRESENTATIONS: DETAILS OF DISCIPLINARY ACTION TAKEN IF ANY: ANY OTHER ACHIEVEMENTS: