Gifts, Hospitality, Sponsorship and Interests Declaration Form (Guidance Notes at the bottom of the page)
During 2017 the Conflict of Interest and Declaration of Interest Policy (Including Gifts, Hospitality, Sponsorship and Fit and Proper Persons) which is available on the Intranet was updated in line with national guidance.
As part of this update and in line with national guidance, it was agreed that certain grades and groups of staff are required to submit a declaration of interest annually.
Annually, the Board are asked to sign a Declaration of Interest and the following groups of staff (section 8.2 of the policy) are required to submit a declaration even if it is a nil return:
Council of Governors
Grade 8a and above
The link to the national guidance is https://www.england.nhs.uk/ourwork/coi/ informs you of what should be declared and the general rule is that if in doubt declare it. Please use the online declaration form to submit your declarations even if it is a nil return. Please include:
Shareholdings and other ownership interests
Clinical private practice
Please complete all fields marked with an astrix (*)
Medcial in Training
AFC Band 8a and above
AFC Band 5-7
AFC Band 1-4
Interests to Declare
No Interests to Declare
The information submitted will be held by Luton and Dunstable University Hospital NHS Foundation Trust (L&D) for personnel or other reasons specified on this form and to comply with the
organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that L&D holds.
I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to L&D as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, internal disciplinary, or professional regulatory action may result.
I give my consent for this information to published on registers that L&D holds.
If consent is NOT given please give reasons:
Guidance Notes for Completion of Interests Declaration Form
Name and Role:
Insert your name and your position/role in relation to the Organisation you are making the return to
Description of Interest:
Provide a description of the interest that is being declared. This should contain enough information to be meaningful (e.g. detailing the supplier of any gifts, hospitality, sponsorship, etc). That is, the informaiton provided should enable a reasonable person with no prior knowledge should be able to read this and understand the nature of the interest.
Types of interest:
Financial interests - This is where an individual may get direct financial benefits from the consequences of a decision they are involved in making
Non-financial professional interests - This is where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making, such as increasing their professional reputation or status or promoting their professional career
Non-financial personal interests - This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit, because of decisions they are involved in making in their professional career
Indirect interests - This is where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making
A benefit may arise from both a gain or avoidance of a loss.
Detail here when the interest arose and, if relevant, when it ceased
This field should detail any action taken to manage an actual or potential conflict of interest. It might also detail any approvals or permissions to adopt certain course of action