HREB APPENDIX H: DISCLOSURE OF FINANCIAL INTERESTS

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NAME: 1. Please review carefully definitions on the back of this page for words in Bold with initial letters capitalized. 2. Please make as many photocopies of this page as you will need to record each Entity on a separate page.

Do you or any member of your Family or any Associated Entity possess a Significant Financial Interest: in, or have you or they in the past twelve months received financial benefit in dollars or in kind from (i) entities not controlled by the University of Ottawa Heart Institute whose financial interests would reasonably appear to be affected by your activities at the University of Ottawa Heart Institute; or (ii) that would reasonably appear to be affected by activities funded or proposed for funding by the Canadian Institutes of Health Research, Heart & Stroke Foundation or Natural Sciences and Engineering Research Council. Yes No

NAME OF ENTITY: (omit government agencies and part-time clinical care Annual income from Entity, including fair value of non- coverage) monetary payments: For Profit? Yes No <$10,000 $10,000 $50,000 >$50,000 Value of equity/ownership interest (including options): Activities or products of the Entity which relate to your <$25,000 >$25,000 current or prospective UOHI based research or educational Percent equity/ownership, issued and outstanding: <5% 5-20% 21-50% >50% activities: Are shares/equity publicly traded? Yes No Are these held in a mutual fund? Yes No How many days per month do you devote to this Entity? Please check all activities in which you participate that might relate to the activities of the Entity Sponsored Research. (Please list all agreements) Please check each category applicable to your (or any Consulting, scientific advisor member of your Family or any Associate Corporate Entity) Clinical care including referral of patients or specimens Financial Interest in this Entity Director, Executive Position or other interest employee Consulting Income position Stock, stock option, or partnership share which you Assign or supervise the research work of students, acquired by purchase (including mutual funds) residents, fellows or other faculty Stock, stock option, or partnership share which you Assign or supervise the clinical care activities of students acquired through the provision of service(s). Salary for residents, fellows or other faculty Support for your Sponsored Research Make or influence decisions regarding purchasing by/for Support for your other research third parties in contractual relationships with University Salary for Executive Position of Ottawa Heart Institute or affiliated institutions Salary for other employee position Business development, clinical market information, Compensation for service on Boards of Directors financing advice Honoraria, except for occasional talks at non-profit Other (Please specify). educational institutions Royalties (either direct or through institutional royalty Please add any explanations or questions you may have: sharing policies) for inventions, etc. Royalties for publications promoting this Entity Gift, gratuity or other. Please specify below.

Do you conduct research and/or supervise students or faculty I have answered in full and to the best of my ability and will in the conduct of research not otherwise disclosed in this form update promptly if my circumstances change. that could affect the value of any technology which you have This is page of a total of pages that I am enclosing. developed? Yes No (If Yes, please specify.) ______/ / Signature Date Definitions

(a) An “Associated Entity” of a University of Ottawa Heart Institute Investigator means any trust, organization or enterprise other than the University of Ottawa Heart Institute or any affiliated Hospital over which the Investigator, alone or together with their Family, exercises a controlling interest.

(b) “Business” means any corporation, partnership, sole proprietorship, firm, franchise, association, organization, holding company, joint stock company, receivership, business or real estate trust, or any other legal entity organized for profit or charitable purposes, but excluding the University of Ottawa Heart Institute, any affiliated Hospital, any Private Medical Practice, or any other entity controlled by, controlling, or under common control with the University of Ottawa Heart Institute or an affiliated hospital.

(c) “Executive Position” refers to any position which includes responsibilities for a material segment of the operation or management of a Business.

(d) “University of Ottawa Heart Institute Investigator” means any person possessing either a full or part-time academic appointments (including fellowship positions) at University of Ottawa Heart Institute or affiliated Institutions.

(e) The “Family” of a University of Ottawa Heart Institute Investigator includes their spouse, minor children, and other persons living in the household.

(f) A “Financial Interest” is an interest in a Business consisting of: (1) any stock, stock option or similar ownership interest in such Business, but excluding any interest arising solely by reason of investment in such Business by a mutual, pension, or other institutional investment fund over which the University of Ottawa Heart Institute Investigator does not exercise control; or (2) receipt of, or the right or expectation to receive, any income from such Business, whether in the form of a fee (e.g., consulting), salary allowance, forbearance, forgiveness, interest in real or personal property, dividend, royalty derived from the licensing of technology, rent capital gain, real or personal property, or any other form of compensation, or any combination thereof.

(g) “Participate” means to be part of the described activity in any capacity, including but not limited to serving as the principal investigator, co-investigator, research collaborator or provider of direct patient care. The term is not intended to apply to individuals who provide primarily technical support or who are purely advisory, with no direct access to the data (e.g., control over its collection or analysis) or, in the case of clinical research, to the trial participants, unless they are in a position to influence the study’s results or have privileged information as to the outcome.

(h) “Private Medical Practice” means the professional services rendered by a physician, including departmental practice plans, and the procedures integral to those services.

(i) “Sponsored Research” means research, training and instructional projects involving funds, materials or other compensation from outside sources under agreements which contain any of the following:

1. The agreement binds the University of Ottawa Heart Institute or affiliated institutions to a line of scholarly or scientific inquiry specified to a substantial level of detail. Such specificity may be indicated by a plan, by the stipulation of requirements for orderly testing or validation of particular approaches, or by the designation of performance targets. 2. A line-item budget is involved. A line-item budget details expenses by activity, function, or project period. The designation of overhead (or indirect costs) qualifies a budget as “line-item”. 3. Financial Reports are required. 4. The award is subject to external audit. 5. Unexpended funds must be returned to the sponsor at the conclusion of the project. 6. The agreement provides for the disposition of either tangible or intangible properties which may result from the activity. Tangible properties include equipment, records, technical reports, theses, or dissertations. Intangible properties include rights in data, copyrights, or inventions.

(j) “Technology” means any compound, drug, device, diagnostic, medical or surgical procedures intended for use in health care or health care delivery.