(adapted from the World Health Organization and American Public Health Association guidelines) 
Public health considerations have a primary importance in all IEA activities including position papers, sponsorship and organization of conferences and other types of scientific meetings, and broader dissemination activities. Measures need to be taken to ensure that the best possible assessment of scientific evidence is achieved in all such activities, in an independent atmosphere free of either direct or indirect pressures.  Thus, to assure the technical integrity and impartiality of the Association, it is necessary to avoid situations in which financial or other interests might affect the outcome of that work. 
Each councilor is therefore asked to declare any interests that could constitute a real, potential or apparent conflict of interest, with respect to his/her involvement in the Association, between (1) commercial entities and the participant personally, and (2) commercial entities and the administrative unit with which the participant has an employment relationship.  “Commercial entity” refers to any company, association (e.g., trade association), organization or any other entity of any nature whatsoever, with commercial interests. 
What is a conflict of interest?   A real conflict of interest means that the councilor or his/her partner (“partner” includes a spouse or other person with whom s/he has a similar close personal relationship), or the administrative unit with which the councilor has an employment relationship, has a financial or other interest that could unduly influence the councilor’s position. An apparent conflict of interest exists when an interest would not necessarily influence the councilor but could result in the councilor’s objectivity being questioned by others.  A potential conflict of interest exists when any reasonable person could be uncertain whether or not should be reported. All of the above-mentioned types of conflicts of interest should be disclosed. 
Different types of financial or other interests, whether personal or with the administrative unit with which the councilor has an employment relationship, can be envisaged and the following list, which is not exhaustive, is provided for your guidance.  For example, the following types of situations should be declared: 
1. a current proprietary interest in a substance, technology or process to be considered in an IEA activity; 2. a current financial interest, e.g. shares or bonds, in a relevant commercial entity (except share holdings through general mutual funds or similar arrangements where the councilor has no control over the selection of shares); 3. an employment, consultancy, directorship, or other position during the past 4 years, whether or not paid, in any relevant commercial entity, or an ongoing negotiation concerning prospective employment or other association with such commercial entity; 4. performance of any paid work or research during the past 4 years commissioned by a relevant commercial entity; 5. payment or other support covering a period within the past 4 years, or an expectation of support for the future, from a relevant commercial entity, even if it does not convey any benefit to the councilor personally but which benefits his/her position or administrative unit, e.g. a grant or fellowship or other payment, e.g. for the purpose of financing a post or consultancy. 
Relevant commercial entities include tobacco and alcohol companies, and manufacturers or distributors of firearms and weapons of mass destruction. In the event that the commercial entity is part of a corporate conglomerate with ties to tobacco, alcohol or the manufacturer of firearms or weapons of mass destruction, the entity as well as the relationship between the donor corporation and the conglomerate would be reviewed.  
Other pertinent concerns regarding relevant commercial entities include:   • Occupational health and safety conditions under which products or services are   produced;  • Employment practices, including commitment to diversity and a living wage;   • Commitment to protection of the environment;   • Record of regulatory compliance;   • Marketing and advertising practices;  • Research and development policy and practices;   • Human rights record;   • Donor’s relevant public policy positions;  • Record of support to public health organizations or public health-related issues and organizations;  • Other past activities will be weighed in relation to IEA’s public policies and public reputation.  

 How to complete this Declaration:   

Please complete this Declaration and submit it to the Secretariat.  Any financial or other interests that could constitute a real, potential or apparent conflict of interest should be declared (1) with respect to yourself or partner, as well as (2) with respect to the administrative unit with which you have an employment relationship.  Only the name of the commercial entity and the nature of the interest is required to be disclosed, no amounts need to be specified (though they may be, if you consider this information to be relevant to assessing the interest).  With respect to items 1 and 2 in the list above, the interest should only be declared if it is current.  With respect to items 3, 4 and 5, any interest during the past 4 years should be declared.  If the interest is no longer current, please state the year when it ceased.  With respect to item 5, the interest ceases when a financed post or fellowship is no longer occupied, or when support for an activity ceases. 
Assessment and outcome:  The information submitted by you will be used to assess whether the declared interests constitute an appreciable real, potential or apparent conflict of interest.  Such conflict of interest will, depending on the situation, result in (i) you being asked not to take part in council deliberations or other activities of the Association regarding that particular interest, or (ii) if deemed by the Association to be appropriate to the particular circumstances, and with your agreement, you taking part in the deliberations and your interest being publicly disclosed. 

Declaration:  Have you or your partner any financial or other interest in any relevant commercial entities (as defined above), which may be considered as constituting a real, potential or apparent conflict of interest?     
Yes:      No:       If yes, please give details in the box below. 


Type of interest, e.g. patent, shares, employment, association, payment (including details on any compound, work, etc.) 
Name of commercial entity 
Belongs to you, partner or unit? 
Current interest? (or year ceased) 


Is there anything else that could affect your objectivity or independence in participating in IEA activities, or the perception by others of your objectivity and independence? ____________________________________________________________________________________ 
I hereby declare that the disclosed information is correct and that no other situation of real, potential or apparent conflict of interest is known to me.  I undertake to inform you of any change in these circumstances, including if an issue arises during the course of my term as IEA councillor. 
_______________________________   ______________________________
Signature                                       Name

 _______________________________   _______________________________ 

Date                                                 Institution