Self-declaration form for relationships with parties with commercial interests in health care

"*" indicates required fields

Title of the course/conference*

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Venue

Date

Location

Pursuant to Article 76, paragraph 4, of the State-Regions Agreement dated February 2, 2017, lecturers, moderators, speakers, trainers, and tutors are required to sign a declaration regarding the existence of relationships with stakeholders with commercial interests in health care, held in the two years preceding the event, or the non-existence of such relationships.

The statement must be given to the provider, who shall keep it and make it available at the registered office for at least 5 years.

I, the undersigned

Title*

Indicate for example Dr., Prof., etc.

First Name*

Middle Name

Last Name*

Phone*

Email*

Validation code

The number that is sent to your email inbox after pressing the “Conferma email / Check your e-mail” button should be entered in this field

as a lecturer / moderator / trainer / tutor, in accordance with Article 76, paragraph 4 of the State-Regions Agreement dated February 2, 2017 and paragraph 4.5. of the National Accreditation Manual for the delivery of CME events

Declare*

that in the last two years have had the following relationships with business stakeholders in health care

that in the last two years haven’t had relationships with business stakeholders in health care

Specify here the stakeholders with commercial interests in health care

Privacy Consent*

I authorize the processing of my data in the terms described in the Privacy Policy.

Date

This field is for validation purposes and should be left unchanged.