Declaration of interest of

Insert name of Author

and

Insert name of Company

for the clinical evaluation report of Insert name of medical device / medical device group

The signatory declares by his signature that he has no financial interest in a positive outcome
of the clinical evaluation performed or reviewed by him and by the applicable documents,
referenced in it. The signatory states the following with respect to his financial interest (aside
from the work as clinical evaluator or reviewer, respectively) and relation to the manufacturer
as well as to the evaluated devices:

Applicable Not applicable

Employment by the manufacturer X

Participation as an investigator in clinical studies of the

X
device, or in pre-clinical testing of the device

Ownership/ shareholding possibly affected by the outcome

X
of the evaluation

Grants sponsored by the manufacturer X

Benefits such as travelling or hospitality (if beyond what is

reasonably necessary for the work as an employee or X
external evaluator)

Interests in connection with the manufacturing of the device

X
or its constituents

Interests in connection with intellectual property, such as

patents, copyrights and royalties (whether pending, issued or X
licensed) possibly affected by the outcome of the evaluation

Other interests or sources of revenues possibly affected by

X
the result of the evaluation

Author