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== Policy on Financial Conflict of Interest
Financial Disclosure Statement NAME

DEPARTMENT

PROPOSAL TITLE:

PROPOSAL SUBMITTED TO:

POSITION ON PROJECT:

(Principal investigator, Co-PI, etc.)

I am disclosing the following significant financial interest(s) related to my research (check all that apply) and attaching a written description and supporting documentation that identifies the business enterprise or entity involved, the amount of the interest, and the nature of the relationship.

___ Salary or other payment for services (e.g., consulting fees or honoraria).

___ Direct equity interests (e.g., stocks, stock options, or other ownership interests).

___ Intellectual property rights (e.g., patents, copyrights, and royalties from such rights).

___ Other significant financial interest held by me and/or my immediate family that possibly could affect or be perceived to affect the results of the research activities funded or proposed for funding.

Further, I agree:

To update this disclosure during the period of the award as new reportable significant financial interests are obtained.
To comply with any conditions or restrictions imposed by the College to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award.
If necessary, to have a fully executed conflict management plan in place prior to expenditure of any sponsored project funds.

The above/attached provides an accurate and current statement of all financial interests held by me and my immediate family that would reasonably appear to be affected by the proposed research.

Signed: Date

Submit this form, any supporting documentation, and a draft plan for resolution of any conflict of interest in a sealed envelope marked confidential to the Grants/Contracts Office, Elliot Hall, Rm. 223.

Issued 11/20/95


Updated: October 31, 2006	Feedback \| Email This Page \| Printer-friendly format
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