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Conflict of Interest Disclosure Form

Conflict of Interest Disclosure Form

The form used to disclose interests under our Conflict of Interest Policy.

Complete this form under iRead To Live Initiative’s Conflict of Interest Policy. Return it to the Executive Director, or, for members of the Board of Trustees and Academic Advisory Council, to the Chair at chair@ireadtolive.org.

Part A: Your details

Full name
Role with iRead Trustee / Advisory Council member / Executive Director / Staff / Fellow / Intern / Volunteer / Outside author / Outside reviewer
Current employer and position
Email

Part B: Reason for this disclosure

  • ☐ Joining iRead or the Academic Advisory Council
  • ☐ Annual disclosure for the year:
  • ☐ Writing or reviewing a specific publication. Title:
  • ☐ A new interest acquired since my last disclosure

Part C: Interests to declare

List any interest held now or in the past 24 months, by you or a close family member, that relates to iRead’s work or to the publication named in Part B. Include financial interests, employment, board, council or committee appointments, consultancies, political roles, close personal relationships and gifts or hospitality above nominal value.

Type of interest Organisation or person Nature of the interest Dates Work it relates to
  • ☐ I have no interests to declare.

Part D: Declaration

I confirm that the information in this form is complete and accurate. I have read iRead’s Conflict of Interest Policy and will update this disclosure within 30 days if my interests change.

Signature
Date

Part E: For iRead use

Reviewed by
Date reviewed
Decision No action / Disclose on publication / Step back from the work / Give up the interest or role
Disclosure statement for publication, if any