Registration

First Name

Last Name

I consent to receive electronic messages regarding CADTH’s programs, including input and feedback opportunities, and other events as applicable.

Country

Street

City

Province State Region

Postal Code Zip Code Post Office code

Organization

Department

Job Title

Phone

Fax

Cell Phone

Public Profile

Type of Organization/Group

Review team and Committee members.
Drug Manufacturer/Tumour Group – A drug manufacturer or designated consultant, or clinical and/or research group affiliated with a provincial/territorial cancer agency or Ministry of Health, eligible to file a Drug Submission.
Patient Group – Eligible to provide input and feedback on a Drug Submission.
Clinicians

Additional Information for Patient Group

Section II

Organization Represents

Patients
Caregivers
Other (Please specify)

Organization Represents: Other

Number of Members

Primary Method of Contacting Members

Phone
Mail
E-Mail
Other (Please specify)

Primary Method of Contacting Members: Other

When was the organization established?

Mission Statement or Purpose of Organization

Section III

Organization Classification

Non-Profit
Registered Charitable Organization
Other (Please specify)

Organization Classification: Other

Potential Conflicts of Interest - financial support or grants from a pharmaceutical manufacturer, government or government agency?

Yes
No

Potential Conflicts of Interest - financial support from pharmaceutical manufacturers?

Yes
No

Please specify the name of the Pharmaceutical Manufacturer

Does the organization receive more than 50% of its operating funds from any single funder?

Yes
No

Section IV

Does the organization have a medical liason/lead?

Yes
No

Name of medical liason/lead

Additional Information for Clinicians

Section II

1. Please indicate your specialty. If applicable, please indicate your specific tumour site expertise (e.g., breast cancer, endocrine, gastrointestinal, etc.).

Breast Cancer

Endocrine Cancer

Gastrointestinal Cancer

Genitourinary Cancer

Gynecological Cancer

Head and Neck Cancer

Leukemia

Lung Cancer

Lymphoma

Myeloma

Neurological Cancer

Sarcoma

Skin and Melanoma

Other (Please specify):

2. Please indicate if you are an actively practising physician.

Yes
No

3. Please indicate if you are a member of a medical advisory board or a national or provincial medical organization (e.g., Communities Oncology Network).

Yes
No

If yes, please specify the name of the organization.

Section III

4. Potential Conflicts of Interest – have you been employed or engaged by a pharmaceutical manufacturer or a government or government agency within the past two (2) years?

Yes
No

If yes, please specify the name of the pharmaceutical manufacturer, a government or government agency.

IMPORTANT NOTE: To maintain the objectivity and credibility of CADTH's drug review processes, all participants in the CDR and pCODR review process must disclose any conflicts of interest as part of providing input and feedback on a drug review.

Conflict of interest declaration is requested for transparency — it does not negate or preclude the use of the input.

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