1. Do you, any member of your immediate family, or any business and/or research partner(s) have a financial or other interest in any of the potential research results/ clinical trials?

Yes___ No___

2. Have gratuities, favors, or anything of monetary value been offered to you or accepted by you from any of the potential participants in the proposed research project?

Yes___ No___

3. Have you been regularly employed by any of the associated universities, clinics, pharmaceutical companies, or outside research institutes within the past two years, other than your current affiliation?

Yes___ No___

4. Do you plan to seek or accept future regular employment with any of the associated universities, clinics, pharmaceutical companies, or outside research institute?

Yes___ No___

5. Are there any other conditions which may cause a conflict of interest?

Yes___ No___

If you answered "Yes" to any of the above questions, please provide a written explanation of your answer on the back of this sheet.

I declare that all of the above questions are answered truthfully and to the best of my knowledge.

Signature____________________

Date________________________