MEDICINES CONTROL AGENCY MCA THE GAMBIA DECLARATION OF INVESTIGATOR MCA-F-501/11 Title of the trial Protocol No Name Designation ☐ Co-Investigator ☐ Clinical Trial Coordinator ☐ Responsible Medical Doctor ☐ Research Clinician ☐ Coordinating Investigator (for multicentre trial) ☐ Contract Research Affiliate ☐ Other (specify): Work address 1. I will conduct the trial and fulfill my duties as specified in the clinical trial protocol 2. Using the broad definition of conflict of interest below, I declare that I have no financial or personal relationship(s) which may inappropriately influence me during the conduct of this clinical trial Conflict of interest exists when an investigator or the investigator’s institution has financial or personal relationships with other persons or organisations that inappropriately influence (bias) his or her actions. 3. I have / have not (delete as applicable) previously been involved in a trial at a site which has been closed due to failure to comply with Good Clinical Practice (details attached if applicable) 4. I have / have not (delete as applicable) previously been involved in a trial which has been closed as a result of unethical practices (details attached if applicable) Signature Date MCA-T-501/11, version 2 – 24 January 2025 Page 1 of 1
