ORDIN   Nr. 294 din 19 martie 2004

pentru aprobarea modelului declaratiei de interese a membrilor Consiliului stiintific al Agentiei Nationale a Medicamentului

ACT EMIS DE: MINISTERUL SANATATII

ACT PUBLICAT IN:            MONITORUL OFICIAL  NR. 268 din 26 martie 2004

    Avand in vedere Ordonanta Guvernului nr. 125/1998 privind infiintarea, organizarea si functionarea Agentiei Nationale a Medicamentului, aprobata cu modificari si completari prin Legea nr. 594/2002, cu modificarile si completarile ulterioare,
    vazand Referatul de aprobare al Directiei generale farmaceutice, inspectia de farmacie si aparatura medicala nr. OB 3.068/2004,
    in temeiul Hotararii Guvernului nr. 743/2003 privind organizarea si functionarea Ministerului Sanatatii, cu modificarile ulterioare,

    ministrul sanatatii emite urmatorul ordin:

    Art. 1
    Se aproba modelul declaratiei de interese a membrilor Consiliului stiintific al Agentiei Nationale a Medicamentului, prevazut in anexa care face parte integranta din prezentul ordin.
    Art. 2
    Agentia Nationala a Medicamentului va duce la indeplinire prevederile prezentului ordin.
    Art. 3
    Prezentul ordin va fi publicat in Monitorul Oficial al Romaniei, Partea I.

                              Ministrul sanatatii,
                               Ovidiu Brinzan

    ANEXA 1 *1)

    *1) Anexa este reprodusa in facsimil.

    MINISTERUL SANATATII
    AGENTIA NATIONALA A MEDICAMENTULUI
    Str. Av. Sanatescu nr. 48, sector 1
    Bucuresti
    Tel.: 224.11.02; Fax: 224.34.97

                  DECLARATIE DE INTERESE A MEMBRILOR CONSILIULUI
                STIINTIFIC AL AGENTIEI NATIONALE A MEDICAMENTULUI

    Nume ______________________________________________________________________
    Prenume ___________________________________________________________________
    Functie ___________________________________________________________________

                              Adresa profesionala

    Locul de munca ____________________________________________________________
    Adresa ____________________________________________________________________
    Strada nr. _______________________________________________________________
    Cod postal _____________________ Localitate _______________________________
    Numar de telefon _________ Numar de fax ____________ Adresa e-mail ________

                 Activitate desfasurata in cadrul CS al ANM

    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Presedinte; vicepresedinte; membru

                            A. Interese personale

    Indicati mai jos toate legaturile cu societatile producatoare, distribuitoare sau importatoare de medicamente precum si fata de reprezentantele din tara ale societatilor comerciale producatoare, distribuitoare sau importatoare de medicamente

    1. Participare financiara la capitalul unei societati din categoriile mentionate mai sus
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii ...              Natura participarii financiare
                                          (detinere actiuni)

    2. Activitate/activitati care conduc la o remunerare personala
    2.1. Legatura/legaturi durabila/durabile sau permanenta/permanente (LD) (contract de munca cu remunerare regulata)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura legaturii durabile sau
                                          permanente

    2.2. Interventie/interventii punctuala/punctuale (IP): studii clinice si lucrari stiintifice
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura studiilor sau lucrarilor
                                          stiintifice

    2.3. Interventie/interventii punctuala/punctuale (IP): rapoarte de expertiza
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societati                   Denumirea produsului pentru care s-a
                                          intocmit raportul de expertiza

    2.4.Interventie/interventii punctuala/punctuale (IP): activitati de consiliere
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii de consiliere

    2.5. Interventie/interventii punctuala/punctuale (IP): conferinte, colocvii, actiuni de formare
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Subiectul conferintelor, colocviilor
                                          sau actiunilor de formare

    2.6.  Altele
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

    3. Activitati care conduc la obtinerea unui varsamant in bugetul unei institutii
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Institutia beneficiara a varsamantului

    4. Alta/alte legatura/legaturi (fara remunerare) (FR)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

                      B. Interese ale sotului/sotiei

    Nume si prenume
    ____________________________________  _____________________________________

    Indicati mai jos toate legaturile cu societatile producatoare, distribuitoare sau importatoare de medicamente precum si fata de reprezentantele din tara ale societatilor comerciale producatoare, distribuitoare sau importatoare de medicamente

    1. Participare financiara la capitalul unei societati din categoriile mentionate mai sus
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii ...              Natura participarii financiare
                                          (detinere actiuni)

    2. Activitate/activitati care conduc la o remunerare personala
    2.1. Legatura/legaturi durabila/durabile sau permanenta/permanente (LD) (contract de munca cu remunerare regulata)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura legaturii durabile sau
                                          permanente

    2.2. Interventie/interventii punctuala/punctuale (IP): studii clinice si lucrari stiintifice
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura studiilor sau lucrarilor
                                          stiintifice

    2.3.  Interventie/interventii punctuala/punctuale (IP): rapoarte de expertiza
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societati                   Denumirea produsului pentru care s-a
                                          intocmit raportul de expertiza

    2.4.Interventie/interventii punctuala/punctuale (IP): activitati de consiliere
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii de consiliere

    2.5. Interventie/interventii punctuala/punctuale (IP): conferinte, colocvii, actiuni de formare
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Subiectul conferintelor, colocviilor
                                          sau actiunilor de formare

    2.6.  Altele
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

    3. Activitati care conduc la obtinerea unui varsamant in bugetul unei institutii
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Institutia beneficiara a varsamantului

    4. Alta/alte legatura/legaturi (fara remunerare) (FR)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

          C. Interese ale rudelor de gradul I (parinti, copii, frati)

    Nume, prenume si tipul de rudenie
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________

    Indicati mai jos toate legaturile cu societatile producatoare, distribuitoare sau importatoare de medicamente precum si fata de reprezentantele din tara ale societatilor comerciale producatoare, distribuitoare sau importatoare de medicamente

    1. Participare financiara la capitalul unei societati din categoriile mentionate mai sus
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii ...              Natura participarii financiare
                                          (detinere actiuni)

    2. Activitate/activitati care conduc la o remunerare personala
    2.1. Legatura/legaturi durabila/durabile sau permanenta/permanente (LD) (contract de munca cu remunerare regulata)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura legaturii durabile sau
                                          permanente

    2.2. Interventie/interventii punctuala/punctuale (IP): studii clinice si lucrari stiintifice
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura studiilor sau lucrarilor
                                          stiintifice

    2.3. Interventie/interventii punctuala/punctuale (IP): rapoarte de expertiza
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societati                   Denumirea produsului pentru care s-a
                                          intocmit raportul de expertiza

    2.4. Interventie/interventii punctuala/punctuale (IP): activitati de consiliere
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii de consiliere

    2.5. Interventie/interventii punctuala/punctuale (IP): conferinte, colocvii, actiuni de formare
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Subiectul conferintelor, colocviilor
                                          sau actiunilor de formare

    2.6. Altele
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

    3. Activitati care conduc la obtinerea unui varsamant in bugetul unei institutii
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Institutia beneficiara a varsamantului

    4. Alta/alte legatura/legaturi (fara remunerare) (FR)
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii                  Natura activitatii

               D. Interese ale persoanelor aflate in intretinere

    Nume si prenume
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________

    Indicati mai jos toate legaturile cu societatile producatoare, distribuitoare sau importatoare de medicamente precum si fata de reprezentantele din tara ale societatilor comerciale producatoare, distribuitoare sau importatoare de medicamente

    1. Participare financiara la capitalul unei societati din categoriile mentionate mai sus
                                                                 _
                                                                |_| nici una*
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    ____________________________________  _____________________________________
    Denumirea societatii ...              Natura participarii financiare
                                          (detinere actiuni)

    ___________________________________________________________________________
    Subsemnatul/subsemnata ........................................ declar prin prezenta, pe propria raspundere, ca toate interesele directe sau indirecte susceptibile de a aduce atingere obiectivitatii de care trebuie sa fac dovada in cadrul mandatului meu, sunt enumerate mai sus.

    Ma angajez sa declar imediat orice modificare aparuta in legatura cu cele mentionate mai sus.

    Data _____________________                  Semnatura ___________________

           
    * Se bifeaza casuta, daca este cazul