1. Name of participant:

2. Are you listed in the Public Registry of Lobbyists?

yes no

3. I am participating in this public involvement activity: (Please check one)

as an individual (see Sections B, D, E)
on behalf of an organization (see Sections C, D, E)

1. For the purposes of this public involvement activity, I identify myself as a/an: (Check all that are applicable).

1. Name of organization represented:

2. The scope of my organization's membership is:

3. For the purposes of this public involvement activity, the type of organization that I am representing is: (Check all that are applicable).

4. Mandate of organization (Maximum 500 characters)

5. Does the organization you represent have funding guidelines and/or sponsorship agreements to deal with issues pertaining to funding or contributions?

yes no

1. Direct financial interests

Do you, your spouse, and/or dependent minor child currently hold any of the following direct financial interests with an organization or company likely to be affected by the outcome of this public involvement activity? Please check all that apply, and include the name of the organization or company with which the interest is held, and monetary range. There is no need to identify household member.

2. Indirect financial interests

In the past year, have you, or your organization, received any of the following from an organization or company likely to be affected by the outcome of this public involvement activity, other than your present employer? Please check all that apply, and, where applicable, include: whether the payment or support was received by you, your organization, or both; the name of the organization or company who provided the support; and the monetary range.

Intellectual interests

3. In the past year, have you provided formal advice or opinion to industry, a government organization (international, foreign, Canadian federal, provincial or municipal) or a non-government organization (for instance by participating on an advisory body) on issues of relevance to the topic under consideration?

yes no

Please indicate the date, the subject on which you provided the advice or opinion, and who you provided it to.

4. Have you or your organization made public a statement (including speeches, lobbying, etc.) or a point of view (including in papers, articles, journals, or other publications) on issues of relevance to the topic under consideration at this public involvement activity?

yes no

If yes, please list the top three most relevant (in your opinion), and indicate the date and title of the statement or speech, and publication or venue as applicable.

5. Do you or your organization have any of the following professional or volunteer affiliations with an organization with an interest in, or likely to be affected by, the outcome of this public involvement activity?

Please check all that apply, and indicate the name of the organization or company.

1. In the past year, have you or your organization received a grant or contribution from Health Canada?

yes no

If yes, please indicate the date, project title, and the relevant Branch of Health Canada.

2. In the past year, have you or your organization participated in any other Health Canada public involvement activities, such as workshops, focus groups, roundtables, electronic consultations, public forums, or bilateral meetings?

yes no

If yes, please indicate the date, title or topic of the public involvement activity, and the relevant Branch of Health Canada.