International Patient Decision Aid Standards (IPDAS) Collaboration

Declaration of Interest FormThe IPDAS Declaration of Interest Form is used to manage conflicts, promote transparency, and adopt
unbiased decisions that are in the best interest of the collaboration. Effectively managing interests – andidentifying potential conflicts – is essential if policy makers, healthcare professionals, and thepatients/public, are to maintain confidence in our work.
Why Must I File?

The information you provide on this form will be used to assess if you
have any potential conflicts of interest. Information will be disclosed on
the IPDAS website in the interest of transparency.

Who must complete it? Members of the IPDAS Steering Committee and members of special
IPDAS working groups.
When Must I File?

The report is due prior to assuming a position and updated yearly.

Reporting Period?

Report the required information for the 3 years preceding the date youQuestions(?)

complete this form.
If you have any questions about how to complete this form, please contact
ipdas@ohri.ca

What are the different types of interest?
Direct Interests:
When there is, or could be perceived to be, an opportunity for a person
involved with IPDAS work to benefit. This benefit could be financial or nonfinancial. Non-financial is described as increasing or maintaining theirprofessional reputation (e.g., advocate for a particular group, holds office ofauthority in professional organization, actively involved in an ongoing
research project aimed at determining the effectiveness of a matter underconsideration; published a clear opinion about the matter underconsideration).
Indirect Interests:
When there is, or could be perceived to be, an opportunity for a third party
closely associated with the person in question to benefit. This could bethrough a close association with another person or organization that has afinancial or non-financial interest (defined above) and could benefit from adecision the person is involved in making through their work on an IPDAS
committee.
What are the responses to declared interests?
a. No action other than the process of open declaration.
b. Partial exclusion from developing recommendations and decision-making on the matter
relating to the interest – may provide advice because of their expert knowledge;c. Complete exclusion from having input to a specific topic.

IPDAS Version 1.0; 08/2018

International Patient Decision Aid Standards (IPDAS) Collaboration

Declaration of Interest Form
Name/ email

Kirsten McCaffery

kirsten.mccaffery@sydney.edu.au

Position/Title NHMRC Professorial Research Fellow
Employer

The University of Sydney

Country

Reporting Status
NewAustralia

Date of Completion (mm/dd/yy) 09/10/18
RenewalFor each statement below, check Yes or No to describe your situation in the last 3 years
or next 12 months.

YesI. I have reportable assets or sources of income for myself, my spouse, or my dependentchildren (research support, grants, scholarships, awards, consulting fees, royalties, patients).
II. I have reportable liabilities (debts) for myself, my spouse, or my dependent children.
III. I have a reportable outside position(s) for myself.
IV. I have reportable agreements or arrangements for myself.
V. I have reportable gifts or travel reimbursements for myself, my spouse, or my dependent children.

If you selected Yes for any statement, you must describe the reportable interests that you have below
Type ofinterest

Description of interest

Dateinterest
began

Dateinterestceased

Comments/explanation (for IPDAS)(add rows as needed)

I certify that the statements I have made on this form are true, complete, and correct to the best of myknowledge. I do give my consent for this information to be published on the IPDAS website.
Date of Completion (mm/dd/yy)

09/10/18

Signature
FOR INTERNAL REVIEWERS’ USE ONLY:
Signature and Title of IPDAS Reviewer

E-mail Address

Comments of Reviewer

Approved by the IPDAS Steering Committee: August 20

IPDAS Version 1.0; 08/2018

Date (mm/dd/yy)

NoX
X
X
X
X