Faculty Disclosure of Commercial Support Form

The Dubai Healthcare City Authority-Regulator (DHCA-R) must ensure balance, independence, objectivity, and scientific rigor in all
its approved or sponsored educational activities. All faculty members participating in a DHCA-R approved activity are expected to
disclose to the activity audience any significant financial interest or other relationship (1) with the manufacturer(s) of any commercial
product(s) and/or provider(s) of commercial services discussed in an educational presentation and (2) with any commercial supporters
of the activity. (Significant financial interest or other relationship can include such things as grants or research support, employee,
consultant, major stock holder, member of speakers bureau, etc.). The intent of this disclosure is not to prevent a speaker with a
significant financial or other relationship from making a presentation, but rather to provide listeners with information on which they
can make their own judgments. Faculty or sponsor relationships with commercial supporters will be disclosed to participants in
printed materials such as brochures and or syllabi. In the case of regularly scheduled events, such as grand rounds, disclosure shall be
made by the moderator of the activity and written documentation of the said disclosure entered into the CPD office file. It remains for
the audience to determine whether the speakers interests or relationships may influence the presentation with regard to exposition or
conclusion.
Should your presentation include discussion of any unlabeled/investigational use of a commercial product, you are required to disclose
this to the participants.
ACTIVITY TITLE: ________________________________________________________DATE OF ACTIVITY:
TOPIC
(if different from activity title):
SPEAKER/PRESENTER/FACULTY NAME: ________________________________________________________________
PLEASE REVIEW EACH SECTION CAREFULLY. TICK I OR II AND III & IV.
I. I do not have a significant financial interest or other relationship with any manufacturers of commercial products.
II. I have the following significant financial interests, arrangements, or affiliations with the corporate organizations listed below:
Grant/research support: ___________________________________________________________________________
Consultant: _____________________________________________________________________________________
Major stock shareholder: __________________________________________________________________________
Other financial/material interest: ____________________________________________________________________
III. I attest that I am not receiving direct payments from a commercial entity with respect to this CPD activity.
IV. Please tick as appropriate:
I plan on discussing unlabeled/investigational uses of a commercial product and will disclose this to the audience.
I do not plan on discussing unlabeled/investigational uses of a commercial product.
Disclaimer
I declare and affirm that this form has been examined and completed by me to the best of my knowledge and belief.
All information supplied is hereby affirmed to be true and correct.

Speaker/Presenter/Faculty Signature

Date :