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Conflict-of-Interest Declaration

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FORMULARY ADDITION REQUEST CONFLICT OF INTEREST STATEMENT

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NOTE: This must be submitted along with the actual Request form if the person submitting the Request is not a member of the Formulary Committee. A copy of the Formulary Committee’s Policy on Conflict of Interest Management is attached.

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Generic Name________________ Trade Name_______________

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Substantial Involvement with a Competing Organization - □Yes □No

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Please describe if:

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  • 1) A member of a health insurance company or another health system Pharmacy and Therapeutics Committee.

  • 2) Another health system medical staff officer.

  • 3) A member of a group practice primarily affiliated with another health system.

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Substantial Involvement with a Company which Manufactures the Product or Competes with the Product’s Company - □Yes □No

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Please describe if:

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  • 1) Receiving financial income or support in the last 12 months of more than $100 for research, attendance at a company supported seminar, travel to an out-of-town meeting, or participation in a company sponsored speaker’s bureau.

  • 2) Receiving pharmaceutical products from the company in the last 12 months for personal or family use, gifts for family or personal use, or samples for use other than as a courtesy for patients.

  • 3) Maintaining in the last 12 months a substantial ownership of stock (>10% of outstanding shares) in the company having >30% of its revenue from sales to this organization, its affiliated organizations, or another local health system.

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Substantial Inside Information - □Yes □No

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Please describe if there are other outside relationships for which involvement in this request may be actually or potentially perceived as affecting the decision of the committee such as:

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  • 1) Having a substantial position of authority in another organization which might affect a member of the committee for employment or medical staff privileges.

  • 2) Disclosing information about this request to another organization directly or indirectly which might give this organization, the other organization, or the requester an unfair advantage.

  • 3) Receiving substantial assistance from the company or its representative that manufactures the requested product in the preparation of this Formulary Addition Request.

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