IBLCE Speaker Disclosure & Conflict of Interest Declaration Form IBLCE Speaker Disclosure & Conflict of Interest Declaration Form Providers: Preferred Providers cannot be recognised for programmes sponsored by or connected to organisations that violate the International Code of Marketing of Breast-milk Substitutes (WHO Code) and subsequent resolutions, including programmes where a speaker has identified connection to an organisation that falls within such scope. It is the responsibility of the Preferred Provider to confirm that educational content is free from commercial influence and must collect and retain completed Speaker Disclosure & Conflict of Interest Declaration Forms from each speaker. Providers must actively identify and mitigate relevant financial relationships prior to the delivery of the education. Name of Provider Name of Course * Course Date(s) * It is the policy of IBLCE to make the best efforts to ensure balance, independence, objectivity, and scientific rigor in educational activities which are recognised for IBLCE Continuing Education Recognition Points (CERPs). All speakers/presenters participating in any programme recognised for IBLCE CERPs are expected to disclose to the programme audience any affiliations that may have a bearing on the subject matter of their presentation. Such affiliations include, but are not limited to: • Companies and commercial entities as defined in the IBLCE Minimising Commercial Influence on Education Policy • Any other persons or entities related to the subject matter of the presentation topic or the general topic of the programme as a whole. In the case that, a competing interest is identified where the competing interest is connected to an organisations that falls within the scope of the WHO Code, it is the responsibility of the Preferred Provider to carefully consider the affiliation prior to submission for CERPs. IBLCE will review all disclosed conflicts and consider them on a case-by-case basis. IBLCE has the sole authority to make the final determination on a speaker’s eligibility to speak at a CERPs recognised programme(s). Examples of a competing interest or affiliation include, but are not limited to: • grant/research support; • receipt of honoraria, royalties, consulting fees, travel, or any other financial benefit received from a commercial interest; • acting as a consultant/independent contractor, employee, officer or director, or having a financial interest; participation as part of a speaker’s bureau or being a regular contributor to a publication; • having a close friend or family member who is an officer, director, employee, or who has a financial interest; and any other financial or material support. Definitions for relevant financial relationships and commercial interest can be found in the IBLCE Minimising Commercial Influence on Education Policy Speaker Disclosure & Conflict of Interest Declaration Form Speakers: Please read the above policy and then provide the following information. Promptly return the completed form to the Programme Provider. Name * First * Last Email * Confirm Email * IBCLC Credential Number (L-#) (if applicable): Please Select One * I have no actual or potential declarations to make in relation to this programme. I have a relevant financial relationship, competing interest, or an affiliation that could be perceived as having a bearing on my presentation. I have listed all relevant and current financial, competing interests, or affiliations below. Competing Interest/Affiliation * Name of Person/Organization * Competing Interest/Affiliation Name of Person/Organization Competing Interest/Affiliation Name of Person/Organization Competing Interest/Affiliation Name of Person/Organization I attest that the information provided above is accurate and complete. I understand that this information will be reviewed by IBLCE and/or the Preferred Provider to assess potential conflicts and to ensure compliance with CERPs recognition standards. I acknowledge that failure to fully disclose or mitigate relevant financial relationships, competing interests, or affiliations may disqualify my eligibility to be a speaker and the course for CERPs recognition. Signature * signature keyboard Clear Date * Copyright © 2017-2025, International Board of Lactation Consultant Examiners. All rights reserved. www.iblce.org April 22, 2025 Submit If you are human, leave this field blank.
