EUROPEAN UNION OF MEDICAL SPECIALISTS The European Accreditation Council for Continuing Medical Education — EACCME® Institution of the UEMSaisbl T +32 2 649 51 64 F +32 2 640 37 30 [email protected]

AVENUE DE LA COURONNE, 20

BE- 1050 BRUSSELS www.eaccme.eu

Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members)

NAME •

EOtevinl

AFFILIATION:

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In accordance with criterion 24 of document UEMS 2012/30 "Accreditation of Live Educational Events by the EACCME", all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

0 I have no potential conflict of interest to report

)2S( I have the following potential conflict(s) of interest to report

Type of affiliation / financial interest

Name of commercial company

Receipt of grants/research supports:

IvOnre uvv/aA60,,,

Receipt of honoraria or consultation fees: Participation in a company sponsored speaker's bureau:

N/A • -

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Stock shareholder: Spouse/partner:

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Other support (please specify):

Signature:

Date:

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UEMSai,b, — Union Européenne des Médecins Spécialistes I Avenue de la Couronne 20, BE-1050 Bruxelles IBAN BE28 0001 3283 3820 I BIC (SWIFT) BPOTBEB1 I VAT n° BE 0469.067.848

​EUROPEAN UNION OF MEDICAL SPECIALISTS The European Accreditation Council for Continuing Medical Education – EACCME® Institution of the UEMSaisbl

​AVENUE DE LA COURONNE, 20 ​BE- 1050 BRUSSELS ​www.eaccme.eu

​T +32 2 649 51 64 ​F

+32 2 640 37 30

​[email protected]

Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members)

NAME : Adam Finn AFFILIATION: University of Bristol In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the EACCME”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

● I have no potential conflict of interest to report ● I have the following potential conflict(s) of interest to report

√

Type of affiliation / financial interest

Name of commercial company

Receipt of grants/research supports:

Novartis, Sanofi Pasteur MSD, GSK Pfizer, Takeda, Alios (Payment to University of Bristol or University Hospitals Bristol)

Receipt of honoraria or consultation fees:

Novartis, Sanofi Pasteur MSD, GSK Pfizer, Takeda, Alios (Payment to University of Bristol)

Participation in a company sponsored speaker’s bureau: Stock shareholder: Spouse/partner: Other support (please specify):

​Signature:

​Date: 24/10/2013

​ ​ UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848

​EUROPEAN UNION OF MEDICAL SPECIALISTS The European Accreditation Council for Continuing Medical Education – EACCME® Institution of the UEMSaisbl

​AVENUE DE LA COURONNE, 20 ​BE- 1050 BRUSSELS ​www.eaccme.eu

​T +32 2 649 51 64 ​F

+32 2 640 37 30

​[email protected]

Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members)

NAME : Brad Gessner. AFFILIATION: Agence de Medecine Preventive In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the EACCME”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re-imbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

● I have the following potential conflict(s) of interest to report Type of affiliation / financial interest Name of commercial company Receipt of grants/research supports:

Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau: Stock shareholder: Spouse/partner:

I work at AMP which receives unrestricted support from sanofi Pasteur and grant specific support from Crucell, GSK, Merck, Novartis, Pfizer, and sanofi Pasteur.

Other support (please specify):

Signature:

​Date: October 10, 2013

​

​

​ UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848

E U R O P E A N   U N I O N   O F   M E D I C A L   S P E C I A L I S T S   T h e   E u r o p e a n   A c c r e d i t a t i o n   C o u n c i l   f o r   C o n t i n u i n g   M e d i c a l   E d u c a t i o n   –   E A C C M E ®   I n s t i t u t i o n   o f   t h e   U E M S a i s b l        

AVENUE  DE  LA  COURONNE,  20     BE-­‐  1050  BRUSSELS   www.eaccme.eu      

   

T    +32  2  649  51  64   F    +32  2  640  37  30     [email protected]  

 

 

Conflict  of  Interest  Disclosure  Form   (to  be  completed  by  scientific/organising  committee  members)       NAME  Neal  Halsey……………….     AFFILIATION:  Johns  Hopkins  University……….   In  accordance  with  criterion  24  of  document  UEMS  2012/30  “Accreditation  of  Live  Educational  Events  by  the   EACCME”,  all  declarations  of  potential  or  actual  conflicts  of  interest,  whether  due  to  a  financial  or  other   relationship,  must  be  provided  to  the  EACCME®  upon  submission  of  the  application.  Declarations  also  must  be   made  readily  available,  either  in  printed  form,  with  the  programme  of  the  LEE,  or  on  the  website  of  the   organiser  of  the  LEE.  Declarations  must  include  whether  any  fee,  honorarium  or  arrangement  for  re-­‐ imbursement  of  expenses  in  relation  to  the  LEE  has  been  provided.  

 

DISCLOSURE       q  I  have  no  potential  conflict  of  interest  to  report   qX  I  have  the  following  potential  conflict(s)  of  interest  to  report     Type  of  affiliation  /  financial  interest  

Name  of  commercial  company  

Receipt  of  grants/research  supports:    

None  

Receipt  of  honoraria  or  consultation  fees:    

Merck  and  Novartis  for  service  on  Safety   Monitoring  Committees.    

 

Baxter  for  a  consultation  on  Lyme  disease   GlaxoSmithKline  for  expert  review  regarding  a   lawsuit  on  vaccine  schedules.  

 

Participation  in  a  company  sponsored  speaker’s  bureau:    

None  

Stock  shareholder:    

None  

 

UEMSaisbl  –  Union  Européenne  des  Médecins  Spécialistes  ǀ  Avenue  de  la  Couronne  20,  BE-­‐1050  Bruxelles   IBAN  BE28  0001  3283  3820  ǀ  BIC  (SWIFT)  BPOTBEB1  ǀ  VAT  n°  BE  0469.067.848  

U N I O N   E U R O P É E N N E   D E S   M É D E C I N S   S P É C I A L I S T E S   E U R O P E A N   U N I O N   O F   M E D I C A L   S P E C I A L I S T S   Association  internationale  sans  but  lucratif  –  International  non-­‐profit  organisation  

 

 

Spouse/partner:    

None  

Other  support  (please  specify):  

 

 

Signature:

 

 

   

   

 

 

Date:  Dec  10,  2013  

 

AVENUE  DE  LA  COURONNE,  20     BE-­‐  1050  BRUSSELS   www.uems.net    

     

T    +32  2  649  51  64   F    +32  2  640  37  30     [email protected]  

EUROPEAN  UNION O F  MEDIC AL SPECIALISTS  T h e European Accred itation  Co uncil  for  Continuing  Medical Education  –  EAC CME®  Institution of the UEMSaisbl       

AVENUE DE LA COURONNE, 20   BE‐ 1050 BRUSSELS  www.eaccme.eu    

   

T  +32 2 649 51 64  F  +32 2 640 37 30   [email protected] 

 

 

Conflict of Interest Disclosure Form  (to be completed by scientific/organising committee members)    NAME : …Paul‐Henri Lambert    AFFILIATION: Centre of Vaccinology‐ University of Geneva  In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the  EACCME”, all declarations of potential or actual conflicts of interest, whether due to a financial or other  relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be  made readily available, either in printed form, with the programme of the LEE, or on the website of the  organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re‐ imbursement of expenses in relation to the LEE has been provided. 

DISCLOSURE       I have no potential conflict of interest to report  X  I have the following potential conflict(s) of interest to report    Type of affiliation / financial interest 

Name of commercial company 

Receipt of grants/research supports: 

 

Receipt of honoraria or consultation fees: 

GSK‐Novartis‐Glycovaxyn‐Hookipa 

Participation in a company sponsored speaker’s bureau: Stock shareholder:   Spouse/partner:  Other support (please specify): 

 

 

Signature: 

 

  Date: 25 Nov 2013 

 

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE‐1050 Bruxelles  IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848 

EU ROP EAN UN ION OF MEDICAL SP ECIALISTS The European Accreditation Council for Continuing Medical Education – EACCME® Institution of the UEMSaisbl AVENUE DE LA COURONNE, 20 BE- 1050 BRUSSELS www.eaccme.eu

T +32 2 649 51 64 F +32 2 640 37 30 [email protected]

Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members)

NAME : Mark A. Miller AFFILIATION: The National Institutes of Health/Fogarty International Center In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the EACCME”, all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement of expenses in relation to the LEE has been provided.

DISCLOSURE X I have no potential conflict of interest to report  I have the following potential conflict(s) of interest to report

Type of affiliation / financial interest

Name of commercial company

Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau: Stock shareholder: Spouse/partner: Other support (please specify):

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE-1050 Bruxelles IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848

U N IO N E U R O PÉ E N N E D E S M É D E C IN S SP É C I A L I ST E S E UR O P E A N UN IO N O F ME D IC A L SP E C IA L IST S Association internationale sans but lucratif – International non-profit organisation

Signature:

AVENUE DE LA COURONNE, 20 BE- 1050 BRUSSELS www.uems.net

Date: 10/21/2013

T +32 2 649 51 64 F +32 2 640 37 30 [email protected]

EUROPEAN  UNION O F  MEDIC AL SPECIALISTS  T h e European Accred itation  Co uncil  for  Continuing  Medical Education  –  EAC CME®  Institution of the UEMSaisbl       

AVENUE DE LA COURONNE, 20   BE‐ 1050 BRUSSELS  www.eaccme.eu    

   

T  +32 2 649 51 64  F  +32 2 640 37 30   [email protected] 

 

 

Conflict of Interest Disclosure Form  (to be completed by scientific/organising committee members)    NAME: Siegrist Claire‐Anne    AFFILIATION: University of Geneva, Switzerland  In accordance with criterion 24 of document UEMS 2012/30 “Accreditation of Live Educational Events by the  EACCME”, all declarations of potential or actual conflicts of interest, whether due to a financial or other  relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be  made readily available, either in printed form, with the programme of the LEE, or on the website of the  organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for re‐ imbursement of expenses in relation to the LEE has been provided.   

DISCLOSURE       I have no potential conflict of interest to report  X I have the following potential conflict(s) of interest to report    Type of affiliation / financial interest 

Name of commercial company 

Receipt of grants/research supports: 

sanofipasteur 

Receipt of honoraria or consultation fees: 

 

Participation in a company sponsored speaker’s bureau: 

 

Stock shareholder:  

 

Spouse/partner:  Other support (please specify): 

Signature:   

 

 

 

 

 

 

Date: 11.10.2013 

 

UEMSaisbl – Union Européenne des Médecins Spécialistes ǀ Avenue de la Couronne 20, BE‐1050 Bruxelles  IBAN BE28 0001 3283 3820 ǀ BIC (SWIFT) BPOTBEB1 ǀ VAT n° BE 0469.067.848 



EUROPEAN UNION OF MEDICAL SPECIALISTS The European Accreditation Council for Continuing Medical Education - EACCME® Institution of the UEMSaISbI AVENUEDELACOURONNE, 20 BE-1O5OBRUSSELS www.eaccme.eu

T +3226495164 F +3226403730 [email protected]

Conflict of Interest Disclosure Form (to be completed by scientific/organising committee members)

NAME : Chris Wilson AFFILIATION: Bill & Melinda Gates Foundation In accordance with criterion 24 of document UEMS 2012/30 "Accreditation of Live Educational Events by the EACCME", all declarations of potential or actual conflicts of interest, whether due to a financial or other relationship, must be provided to the EACCME® upon submission of the application. Declarations also must be made readily available, either in printed form, with the programme of the LEE, or on the website of the organiser of the LEE. Declarations must include whether any fee, honorarium or arrangement for reimbursement of expenses in relation to the LEE has been provided.

DISCLOSURE

have no potential conflict of interest to report I have the following potential conflict(s) of interest to report

Type of affiliation I financial interest

Name of commercial company

Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker's bureau: Stock shareholder: Spouse/partner: Other support (please specify):

Signature:

Date:

01 )-

UEMSaIsbI - Union Européenne des Médecins Spécialistes Avenue de Ia Couronne 20, BE-1050 Bruxelles IBAN BE28 0001 3283 3820 I BIC (SWIFT) BPOTBEB1 I VAT n° BE 0469.067.848