IBLCE Speaker Disclosure & Conflict of Interest Declaration Form IBLCE Speaker Disclosure & Conflict of Interest Declaration Form Providers: CERPs cannot be recognised for programmes sponsored by or connected to organisations that violate of 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 Programme Provider to distribute, collect and retain completed Speaker Disclosure & Conflict of Interest Declaration Forms from each speaker on the Provider’s programme schedule. Furthermore, it is the Programme Provider’s responsibility to provide a copy of the Speaker Disclosure form completed by each speaker of the educational activity with the STP application. Name of Provider Name of Course * Course Date(s) * It is the policy of IBLCE to make best efforts to insure 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 CERP 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 reserves the sole authority to make the final determination on a specific speaker’s eligibility to speak at CERP programmes. Examples of a competing interest or affiliation include, but are not limited to: • grant/research support; • receipt of honoraria, travel, or other benefits; • acting as a consultant/independent contractor, employee, officer or director, or having a financial interest; participation as part of a speaker’sbureau 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. Speaker’s Individual Declaration of Competing Interest or Affiliation 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 * Please Select One * I have no actual or potential declarations to make in relation to this programme. I have a competing interest or affiliation that could be perceived as having a bearing on my presentation. I have listed all current 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 hereby consent to IBLCE processing information about me, including information obtained from the CERP provider, for purposes of verifying my speaking engagement and my affiliation(s) status. Signature * signature keyboard Clear Date * Copyright © 2017-2022, International Board of Lactation Consultant Examiners. All rights reserved. Submit If you are human, leave this field blank.
