2014-2015 Financial Conflict of Interest Disclosure

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Disclosure of Financial Relationship for Sponsored Projects
(08/24/2014-08/23/2015)
 
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This Form shall be completed by all Investigators/Support Personnel/Research Committee Members pursuant to University Policy 3.1.10, Financial Conflict of Interest in Research.

Section A. Financial Interests/Relationships

Report all financial interests/relationships currently held, or held within the past 12 months (or during the previous calendar year for annual disclosures), unless otherwise stated, indicating the amount of the financial interest/relationship and the entity or organization. This form must be updated with 30 days of acquiring any new or additional financial interests/relationships.

1. For Publicly Traded Entities: Payment for Services (Remuneration) and/or Equity (Ownership) Interests.

Have you and/or your spouse or dependents received or will you and/or your spouse or dependents receive any salaries and/or other payments (e.g., consulting fees; honoraria, study design; management position, independent contractor, service on advisory committees or review panels of for-profit entities, board membership of for-profit entities; seminars, lectures or teaching engagements for for-profit entities; any interest that could be affected by the outcome of the research) from any one entity or group of related entities, or do you and/or your spouse or dependents hold any equity interests or ownership interest (e.g., stock, stock options, partnership) that when totaled together for any entity or group of related entities exceeded $5,000 in value during the previous 12 months or that currently as of the date of this disclosure exceed $5,000? NOTE: Equity interests exclude interests in diversified mutual funds, unless you or your spouse/dependents have the ability to directly control the direction of the investments.

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2. For Non-publicly Traded Entities: Payment for Services (Remuneration).

Have you and/or your spouse or dependents received or will you and/or your spouse or dependents receive any salaries and/or other payments (e.g., consulting fees; honoraria, study design; management position, independent contractor, service on advisory committees or review panels of for-profit entities, board membership of for-profit entities; seminars, lectures or teaching engagements for for-profit entities; any interest that could be affected by the outcome of the research) from any one entity or group of related entities, that when totaled together for any entity or group of related entities exceeded $5,000 in value during the previous 12 months or that currently as of the date of this disclosure exceed $5,000?

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3. For Non-publicly Traded Entities: Equity (Ownership) Interests.

Do you and/or your spouse or dependents hold any equity interests or ownership interests (e.g., stock, stock options, partnership) in non-publicly traded entities? NOTE: The threshold for equity (ownership) interests is $0; you must report all such interests here. NOTE: Equity interests exclude interests in diversified mutual funds, unless you or your spouse/dependents have the ability to directly control the direction of the investments.

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4. Reimbursed Travel (for Investigators/Support Personnel involved in PHS-funded projects).

Have you and/or your spouse or dependents received or will you and/or your spouse or dependents receive reimbursement in excess of $5,000 (aggregated per entity) for travel and related expenses (e.g., transportation, lodging, meals, incidentals) that are related to your institutional (professional) responsibilities? NOTE: This does not include travel that is reimbursed by a Federal, state, or local government agency; an institution of higher education; an academic teaching hospital; a medical center; or a research institution that is affiliated with an institution of higher education.

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If Yes, note the following:

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5. Sponsored Travel (for Investigators/Support Personnel involved in PHS-funded projects).

Have you and/or your spouse or dependents received or will you and/or your spouse or dependents had travel and related expenses (e.g., transportation, lodging, meals, incidentals) in excess of $5,000 (aggregated per entity) paid on your behalf (i.e., are not reimbursed) that are related to your institutional (professional) responsibilities? NOTE: This does not include travel that is sponsored by a Federal, state, or local government agency; an institution of higher education; an academic teaching hospital; a medical center; or a research institution that is affiliated with an institution of higher education.

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If Yes, note the following:

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6. Contingent Compensation.

Have you and/or your spouse or dependents received or will you and/or your spouse or dependents receive any compensation that will be contingent on the outcome of the research?

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7. Other Financial Interests or Relationships.

Have you and/or your spouse or dependents received any loans, payments, gifts, in-kind contributions or similar financial interests or relationships that are in any way related to your institutional (professional) responsibilities?

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8. Incentives.

If involved in any research activity, will you receive any money, gift, or anything of monetary value above and beyond the actual costs of enrollment, conduct of the research, and reporting on the results, including, but not limited to, finders fees, referral fees, recruitment bonuses, an enrollment bonus for reaching an accrual goal or similar types of payments?

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9. Intellectual Property or Proprietary Interests.

Do you and/or your spouse or dependents have any intellectual property or proprietary interests related to your institutional (professional) responsibilities, including, but not limited to, a patent, trademark, copyright, licensing agreement, or royalties, licensing fees, or other monies related to the intellectual property or proprietary interest not paid through the University?

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10. Other.

Do you and/or your spouse or dependents have any other interests or relationships (including volunteer services) that might constitute a conflict of interest or an appearance of conflict of interest in connection with the research project?

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Section B. Attestation

I affirm that I:

Have read the University Policy 3.1.10, Financial Conflict of Interest in Research, and agree to abide by its terms.

Will update this Disclosure Form on an annual basis or as any new reportable significant financial interest arises.

Will comply with any resolution plan proposed by the CIRC (and/or IRB, if the project involves human subjects) to manage, reduce or eliminate any actual or potential financial conflict of interest before conducting any research where a conflict of interest has been identified by the CIRC.

Understand that, if I am a PHS-funded Investigator/Support Personnel, information on all financial conflicts of interest will be made publicly accessible.

Understand and agree that if I submit this electronically with a typed signature, this will be considered my legally binding signature.

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