Conflict of Interest Disclosure Form

Transcription

1 I n s t i t u t i o n o f t h e U E M S a i s b l NAME : Florian Lordick AFFILIATION: University Cancer Center Leipzig organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report X I have the following potential conflict(s) of interest to report Participation in a company sponsored speaker s bureau: Other support (Travel support): GSK, Fresenius Biotech Amgen, Biontech, Lilly, Nordic, Roche, Taiho none none none Bayer, Merck, Roche UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

2 UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES EUROPEAN UNION OF MEDICAL SPECIALIST S Association internationale sans but lucratif International non-profit organisation Signature: Date: 8 Oct info@uems.net

3 The European Accredit ation Council for I n s t i t u t i o n o f t h e U E M S a i s b l NAME : Giampaolo Tortora AFFILIATION: Medical Oncology, University of Verona and Comprehensive Cancer Center, University Hospital of Verona. organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report I have the following potential conflict(s) of interest to report Merck, Novartis Novartis, Roche, Merck, Celgene Participation in a company sponsored speaker s bureau: Other support (please specify): Signature: Date: UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

4 I n s t i t u t i o n o f t h e U E M S a i s b l NAME : Marcel Verheij AFFILIATION: The Netherlands Cancer Institute, Amsterdam organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report X I have the following potential conflict(s) of interest to report Elekta, Roche, AstraZeneca Participation in a company sponsored speaker s bureau: Other support (please specify): Signature: Date: 9 October 2015 UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

5 Institution of the UEMS aisbl BE BRUSSELS F NAME : Peter JOHNSON AFFILIATION: University of Southampton, UK organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re- imbursement q I have no potential conflict of interest to report ü I have the following potential conflict(s) of interest to report Participation in a company sponsored speaker s bureau: Janssen, Epizyme Roche, Bristol- Myers Squibb, Takeda, Boerhinger Ingelheim Other support (please specify): Signature: Date: 26 th August 2015 UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE Bruxelles

6 I n s t i t u t i o n o f t h e U E M S a i s b l NAME : G.J.Ossenkoppele AFFILIATION: VU University Medical Center Amsterdam organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report x I have the following potential conflict(s) of interest to report Novartis,Celgene,Immunnogen, BD Novartis, BMS, ARIAD,Celgene,J&J, Sunesis Participation in a company sponsored speaker s bureau:na NA NA Other support (please specify): UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

7 UNION EUROPÉENNE DES MÉDECINS SPÉCIALISTES EUROPEAN UNION OF MEDICAL SPECIALISTS Association internationale sans but lucratif International non-profit organisation Signature: Date:

8 Continuing Medical Education - EACCME Institution of the UEMS.i'bl AVENUE DE LA COURONNE, 20 T BE BRUSSELS F ~",!w'.~ccrne.eu. "cg:editation@uef1j s,net --- -~--~------~_._~------~ ~----~_._~-_.~._---- (to be ~flaa~lfflif.nfilf!ti?rganising eommittee members) Professor of Derma1010gY Departmenl 01 DelT11alolO!ly, Campus Kiel NAME ' Unlversity Hospitaf (UKSH). 'SctrIttllnhlllmslr. 7, D Kiel Germany AFFILIATION:... ~... ~.. In accordanee with criterion 24 of doeument UEMS 2012/30 "Accreditation of live Educational Events by the EACCME", all dedarations of potential or actual confhets of interest, whether due to a financial or other relationship, must be provided to the EACCMEIt upon submission of the application. Declarations also must be made readily available, elther In printed form, with the programme of the LEE, or on the webstte of the o(ganiser of the lee, Declarations must include whether any fee, honorarium or arrangement for re~ imbursement Cl I have no potential eonfuct of Interest to report l!) I have the followlng potential confliet(s) of interest to report Type of affiliation I financial interest Reeeipt of honoraria er consultation fees: Participation in a company sponsored speaker's bureau: Other support (please speeify): Axel D'iQ/',.a1 ~nterw::ht1t'bom.on AI:~J Hw.dlild O~' m-..al«tl Houw::/'I11d. 0. ou. ~"li"w~<lfjjld~_ licl.:k c~di' o.:ü,,,m: ]{l!5jo 1~ H:M:26+!l:j'00' Signature: Hauschild Date: Oetober 12th, 2015 UEMS."w Union Europeenne des Mildecins Speciallstes IAvenue de la Couronne 20, BE-I050 Bruxelles IBAN BE Isie (SWIFT) BPOTBEBll VAT n' BE

9 UK H Khnik [\lr Damlli1tQiog!e, Verwrologie und Al1eIl)Ologie, UNj\IERSITA1SKLINIKUM Sr)lIaswtg-Holllle 0, Campus Klei H<lus 19, Arnold heller-s~raße;, 2"4105 Kiel UNIVERSITÄTSKLINIKUM Schieswig-Hoistein Campus Kiel Klinik für Dermatologie, Venerologie und Allergologie Direktor: Prof. Dr. Thomas Schwarz Zufahrt und Ljeferanschrift: Schlttenhelmstr.7, Kiel... Schwerpunktbereich Dermato-Onkologie und Operative Dermatologie Leiter: Prof. Dr. Axel Hauschild Tel.: (0431) Fax: (0431) Internet: Date: Form for Disclosure of Potential Conflicts of Interest Relationship Type Employment: Consultancies: Honoraria: Speakers bureau: Stock ownership or options: Expert testimony: Trial grants (clinical trial participation): Royalties: Company/Description Amgen, BMS, Celgene, Eisai, GSK, Medlmmune, MelaSciences, Merck Serono, MSD/Merck, Novartis, Oncosec, Roche Pharma Amgen, BMS, Celgene, Eisai, GSK, Medlmmune, MelaSciences, Merck Serono, MSD/Merck, Novartis, Oncosec, Roche Pharma Amgen, BMS, Celgene, Eisai, GSK, MelaSciences, Merck Serono, MSD/Merck, Novartis, Oncosec, Roche Pharma Axel Hauschild, MD Professor of Dermatology Department of Dermatology University Hospital Schieswig-Hoistein Campus Kiel Schittenhelmstr Kiel Germany Phone: Fax: ahauschild@dermatology.uni-kiel.de Universil~skljOllw.m VorstandsmltgliEt(ler Schleswrg Hoistein Prol Dr, Jens Scholl Anstalt des Pater Pansegrau I öffentlichen Rechts Christa Meyer WKicl!

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11 I n s t i t u t i o n o f t h e U E M S a i s b l NAME : Ian Judson AFFILIATION: Royal Marsden Hospital organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report I have the following potential conflict(s) of interest to report Participation in a company sponsored speaker s bureau: Other support (please specify): GSK, PharmaMar, AstraZeneca, Eisai GSK, Clinigen, Merck-Serono, Ariad No UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

12 UNION EUROPÉENNE DES MÉDEC INS SPÉCIALISTES EUROPEAN UNION OF MEDICAL SPECIALISTS Association internationale sans but lucratif International non-profit organisation Signature: Date: 9 th October info@uems.net

13 Institution of the UEMS aisbl NAME : Jan van Meerbeeck. AFFILIATION: Antwerp University Hospital. organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement X I have the following potential conflict(s) of interest to report Astrazeneca, Roche, Boehringer Ingelheim Bayer, Abbvie,BMS, Pfizer Participation in a company sponsored speaker s bureau: Other support (please specify): Signature: Date: October 7, 2015 UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

14 I n s t i t u t i o n o f t h e U E M S a i s b l NAME : Jørn Herrstedt AFFILIATION: Odense University Hospital, Odense, Denmark. organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement I have no potential conflict of interest to report X I have the following potential conflict(s) of interest to report Tesaro Participation in a company sponsored speaker s bureau: Other support (please specify): Signature: Date: October 11, 2015 UEMS aisbl Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles

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