FH Australasia Network

National Familial Hypercholesterolemia Registry

Members of the Board are required to disclose conflicts of interests and update the disclosure statements on an annual basis.

In relation to each conflict topic, please disclose any conflict of interest which may be associated with the development, management or analysis of data collected within the registry. Please see supporting documentation from WA DoH which may assist in identifying any conflicts of interest, and ensure the guideline has been completed and returned along with this form in order for FHAN to declare and potenial / perceived or actual conflicts of interst to the relevant parties. Thank you for your cooperation.

Name / Prof Peter Clifton
Institution / University of South Australia
Address / Level 5 room P5-16 Playford Building, University of South Australia, Adelaide SA 5001 Australia
Email / / Phone / 61403197998
Conflicts / Actual/Perceived/Potential / Benefits Received
Employment / None
Advisory Board / Amgen / honorarium
Lectures / Amgen / honorarium
Meals/beverages/entertainment/gifts / None
Other / None

I declare that the information provided was correct on the date below. In signing this form I agree

·  That I have read, completed and returned Attachement 1 of the accompanying “Managing Conflict of Interest” guidelines produced by the Governement of Westerns Australia Dept. of Health

·  To update this information throughout my involvement with the National FH Registry at least annually

·  Allow the publication of any interests I have disclosed in this form, and any interests declared after I complete this form, on the AAS-FHAN website and in any publications

Signature

Date 3/5/2016

Completed, signed forms may be posted or scanned and emailed to be address below.

A 3/10 Pioneer Avenue, Tuggerah NSW 2259

T +61 2 4356 0007

F +61 2 8078 4843

E

W www.athero.org.au

AAS ABN 17 929 443 544