Conflict of Interest Disclosure Form

For Clinical Trials Investigators

Investigator Name Institution Title of Clinical Trial Date

1. Financial Interests

I or my immediate family have a financial interest related to this clinical trial. If yes, provide details:

2. Personal Relationships

I have a personal relationship that may influence my conduct or interpretation of the trial. If yes, provide details:

3. Intellectual Property

I have intellectual property interests (e.g., patents) related to the subject of the trial. If yes, provide details:

4. Other Conflicts

I have other interests, activities, or relationships that may be perceived as conflicts of interest. If yes, specify:

I declare that I have no conflicts of interest to disclose.

Signature Date