APPENDIX B

Welsh Health Specialised Services Committee

Declaration of Interests

Return for the period 1 April 20__ to 31 March 20__

Name:
Designation:
Committee/
Sub Committee: / Joint Committee / Audit Committee / Quality and Patient Safety Committee / Integrated Governance Committee / Welsh Renal Clinical Network
Wales Neonatal Network Steering Group / All Wales Individual Patient Funding Panel / All Wales Posture and Mobility Service / Secure Services Delivery and Assurance Group / Other (Please state)

For Senior Staff / LHB Officers (Executive Team, Senior Managers, and Clinicians) and other individuals undertaking roles where there is potential for conflict (as determined by the Committee Secretary/Corporate Governance Officer): These individuals must submit a declaration at least annually, even if a nil return.

Please complete either Section A (No Direct or Indirect Pecuniary Interests) or Section B (Pecuniary Interests to Declare)

I declare that the information given on this form is correct and complete and that I will not create a conflict of interest between my Welsh Health Specialised Services Committee appointment and an external organisation or personal business interests. In signing below, I understand that if I knowingly provide false information or fail to disclose relevant information, this may result in disciplinary action, prosecution or civil proceedings. I consent to the disclosure of information on this form and understand that it may be reviewed for the purposes of fraud prevention and detection by NHS counter-fraud specialists. I agree to submit further declarations to update information given here, within 4 weeks of any new interest arising.

Section A – No Direct or indirect pecuniary interests
I, holding an appointment of office with or being an employee of the Welsh Health Specialised Services Committee, give notice that I, my spouse or my partner, have no direct or indirect pecuniary interests which are required to be declared in accordance with the WHSSC Governance and Accountability Framework: Standing order 7.1 - Declaring and recording Joint Committee Members’ interests, Joint Committee Standards of Behaviour Policy and the Code of Conduct for NHS Managers, as detailed within the NHS Wales Values and Standards Behaviour Framework.
Signature: ………………………………………………… Date: ……………………………………………………..
Section B – Pecuniary Interests to declare
I, holding an appointment of office with or being an employee of the Welsh Health Specialised Services Committee have read and understood the Joint Committee Governance and Accountability Framework: Standing order 7.1 - Declaring and recording Joint Committee Members’ interests, Joint Committee Standards of Behaviour Policy and the Code of Conduct for NHS Managers, as detailed within the NHS Wales Values and Standards Behaviour Framework and I hereby declare the following interest(s) in accordance with the aforementioned procedures.
NATURE OF INTEREST: / DATE INTEREST ACQUIRED
DURATION OF INTEREST:
INTEREST OF INDIVIDUAL SPOUSE OR PARTNER: / REMARKS:
(This section is to be used for any notes of clarification and also to indicate when interest ceases)
Signature: ………………………………………………… Date: ……………………………………………………..

FOR OFFICE USE

ENTRY IN REGISTER / NO: / DATE: / BY:

N.B. Once completed should be signed and returned to Corporate Services Officer, WHSSC, Unit 3a, Caerphilly Business Park, Van Road, Caerphilly, CF83 3ED

WHSSC Standards of Behaviour Policy / Page 1 of 2 / Version 2.0