Declaration of Interest Template

The following declaration is in relation to the following clinical trial [Please insert the full title and reference number below]
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Are there any interests, such as economic interests, institutional affiliations or personal interests, which may influence your impartiality? 
 Yes  ☐  No  ☐
If Yes, please give details of all interests:
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I declare that the information provided above is accurate to the best of my knowledge.
Name of investigator: Click or tap here to enter text.
Name of Institution: Click or tap here to enter text.
Signed:  Click or tap here to enter text.                       
Date:  Click or tap to enter a date.