Declaration of Conflict of Interest Form
Declaration of Conflict of Interest Form

Pallium Canada may determine that disclosed potential or actual conflicts contravene the principles and goals set forth for LEAP curriculum and may disallow delivery of the materials. This decision will be relayed to the facilitator and organization in writing prior to the planned LEAP delivery dates.

Select one:

I have/had an affiliation
I have/had an affiliation
Complete this section if you answered "I have/had an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization."


I am a member of an Advisory Board or equivalent with a commercial organization.


I am a member of a Speakers bureau.


I have received payment from a commercial organization (including gifts or other consideration or ‘in kind’ compensation).


I have received a grant(s) or an honorarium from a commercial organization.


I hold a patent for a product referred to in the CME/CPD program or that is marketed by a commercial organization.


I hold investments in a pharmaceutical organization, medical devices company or communications firm.


I am currently participating in or have participated in a clinical trial within the past two years.
I intend to make therapeutic recommendations for medications that have not received regulatory approval (ie. “off-label” use of medications). (You MUST declare all off-label use to the audience during your presentation).

Pallium Canada requires LEAP presentations to be consistent in their use of either generic names, trade names or both generic and trade names during their presentation. Pallium Canada encourages facilitators and associate facilitators to use generic names whenever possible. A trade name may be used to provide participants with an example. 

*Several medications or treatments currently considered best practice and/or supported by evidence in Palliative Care are “off-label” use. These are included in the LEAP courseware. Facilitators are to report these to participants when they are referred to.

Program date  
 
 
 



Required