Register of Interests Declaration

REGISTER OF INTERESTS DECLARATION

NB this form must be completed at the point that an interest is identified, or on an annual basis as part of the appraisal process for all band 7 or above staff. You are required to discuss the interest with your line manager, in order that they are aware of the matter and can take reasonable steps to mitigate any risks.

Name:
Department:
Job Title:
Declarations of interest (please ensure where you declare an interest that you provide full details. A free text box is available at the end of this form if required)
Partnership:
Directorship:
Shareholdings: / Company:
Shares held:
Private Practice: / Capacity:
Commercial Interests
(please state whether self or state relationship if personal or business relation) / Body:
Interest:
Interest in Other Public Bodies (e.g. school governor, local councillor)
Links to Other NHS:
Ownership of land or rental property (e.g. accommodation used by Trust)
Charitable/Voluntary
Outside or secondary Employment
(please specify)
Other Consultancy Work
(please specify)
Other (please specify)
GP: (for Board Members only)

Staff member making the declaration

I ………………………………………………..(name) declare that I do not have any interest/have the above interest which may need to be taken into consideration in relation to the Trusts policies or decisions (*please delete as required). I can confirm that where I have declared an interest I have discussed this with my line manager.

Signed …………………………………………………. Date ………………………

Staff members comments:-

Line manager of staff member making the declaration or other senior manager where appropriate

I ………………………………………………..(name) can confirm that I am the above mentioned staff members line manager (or where appropriate other senior manager) and that he/she has discussed this matter with me in full. I can confirm that I have taken necessary steps within the department to mitigate any risk associated with the declared interest.

Line Manager comments:-

Line Managers Signature...... Date......

NB for all managers, this form should be completed by all staff listed below as a minimum on an annual basis as part of the appraisal process. However, where an interest is identified the form must be completed and discussed with the relevant line manager as soon as practicable.

·  All Board Members including Non-Executive Directors.

·  All staff holding posts at band 7 or above or for those staff not subject to agenda for change terms and conditions who are paid an annual pro rata salary of £30,000 or above.

·  At managers discretion for all other staff as deemed appropriate.

Once completed the form should be retained on the staff member’s personal file and a copy is to be sent to the Corporate Governance Department, Old NICU, Lower Maternity, St Mary’s Hospital for inclusion in the central register.