End of potential conflict of interest notification

Please use this form if you wish to let us know that an interest, you have previously declared, has now come to an end.

Question Title

* 1. Full name

Question Title

* 2. Role

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* 3. Designation

Governor

Executive Board member

Non-executive Board member

DSFS Board member

Medical

Non-medical

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* 4. Decision Maker (BoD, CoG, DSFS Board member, consultants with management roles, agenda for change 8d and above, those directly involved in recruitment, and those deemed as 'authorised signatures'.)

Yes

No

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* 5. Division (Governors and Non-Executive Directors please use Corporate Division)

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* 6. Permission to publish (please choose 'yes' unless there are exceptional circumstances; for example in doing so would risk harm.)

Yes

No - Please state the reason why

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* 7. I have read the Chesterfield Royal Hospital NHS Foundation Trust's 'Managing Conflicts of Interest' policy and confirm that (see option below)

The following interest, previously declared, has now come to an end:

Question Title

* 8. Date interest came to an end.

Date / Time

Date