NATIONAL INSTITUTES OF HEALTH ● NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES ● DIVISION OF AIDS

CONFLICT OF INTEREST CERTIFICATION FOR MEMBERS OF THE MULTINATIONAL DATA AND SAFETY MONITORING BOARD (DSMB)

CONFIDENTIALITY. I am aware of my responsibilities for maintaining the confidentiality of any non-public information that I receive or become aware of while a member of this DSMB, and for avoiding using such information for my personal benefit, the benefit of my associates, or the benefit of organizations with which I am connected or with which I have a financial involvement.

Please indicate any relationships that you or an immediate family member have (e.g. spouses, dependent children, household members, and relatives) in regards to the studies below (e.g. affiliations with study team members at the same University or Department, equity holding or consulting relationship with commercial entities involved with the studies or their direct competitors).

Study / Type of Conflict – Non Pharmaceutical / If yes, nature of conflict / Financial Interest ($)*
Professional / Proprietary / Financial / If >5k/yr., then state the amount
Yes / No / Yes / No / Yes / No
HPTN 083 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
HPTN 084 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
NICHD-P1081 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
SSAT 062 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
WRHI 060/ADVANCE / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
WRHI 052 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

Multinational DSMB Meeting, Nov 8, 2017

* Financial Interest includes income, equity holding, funding, honorariums, donations, etc…

NATIONAL INSTITUTES OF HEALTH ● NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES ● DIVISION OF AIDS

CONFLICT OF INTEREST CERTIFICATION FOR MEMBERS OF THE MULTINATIONAL DATA AND SAFETY MONITORING BOARD (DSMB)

Pharmaceutical Sponsor / Type of Conflict - Pharmaceutical / If yes, nature of conflict / Financial Interest ($)*
Professional / Proprietary / Financial / If >5k/yr., then state the amount
Yes / No / Yes / No / Yes / No
Bill & Melinda Gates Foundation (BMGF)
HPTN 084 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Bristol-Myers Squibb
NICHD-P1081 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Gilead Sciences
HPTN 083; HPTN 084; WRHI060/ADVANCE / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
GlaxoSmithKline Inc.
HPTN 083; NICHD-P1081 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Merck & Co., Inc.
NICHD-P1081 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
Mylan (WRHI060/ADVANCE)
Office of the US Global AIDS Coord. (OGAC)
HPTN 084 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
US Agency for International Dev. (USAID)
HPTN 084 / ☐ / ☐ / ☐ / ☐ / ☐ / ☐
ViiV Healthcare
HPTN 083; HPTN 084; WRHI060/ADVANCE / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

Multinational DSMB Meeting, Nov 8, 2017

* Financial Interest includes income, equity holding, funding, honorariums, donations, etc…

NATIONAL INSTITUTES OF HEALTH ● NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES ● DIVISION OF AIDS

CONFLICT OF INTEREST CERTIFICATION FOR MEMBERS OF THE MULTINATIONAL DATA AND SAFETY MONITORING BOARD (DSMB)

MEMBER’S NAME (PLEASE PRINT) / SIGNATURE / DATE

Multinational DSMB Meeting, Nov 8, 2017

* Financial Interest includes income, equity holding, funding, honorariums, donations, etc…

NATIONAL INSTITUTES OF HEALTH ● NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES ● DIVISION OF AIDS

CONFLICT OF INTEREST CERTIFICATION FOR MEMBERS OF THE MULTINATIONAL DATA AND SAFETY MONITORING BOARD (DSMB)

Multinational DSMB Meeting, Nov 8, 2017

* Financial Interest includes income, equity holding, funding, honorariums, donations, etc…