Author: Catherine Blewett
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Template version 1.2 September 2022

Declaration of Interest Template

This template may be used by Sponsors of clinical trials as part of the application dossier. A separate declaration should be completed and submitted for the Principal/Lead Investigator at each site.
This template has been developed and endorsed by the EU Clinical Trials Expert Group to comply with Regulation (EU) No. 536/2014 Clinical Trials on Medicinal Products for Human Use. 

This declaration is in relation to the following clinical trial [Please insert the full title and reference number below]
Click or tap here to enter text.

Are there any interests, such as economic interests, institutional affiliations or personal interests, which may influence your impartiality? 
 Yes  ☐  No  ☐
If Yes, please give details of all interests:
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I declare that the information provided above is accurate to the best of my knowledge.
Name of investigator: Click or tap here to enter text.
Name of Institution: Click or tap here to enter text.
Date:  Click or tap to enter a date.

The CTR does not require signing individual documents in the clinical trial application – a request for signature could however be subject to national legislation.