ALABAMA A&M UNIVERSITY
OFFICE OF SPONSORED PROGRAMS
Instructions:
This report is to be completed by
AAM
U Faculty/Staff receiving research or teaching awards funded by a
Federal/State Agency or private company. Return the completed/signed form to the Office of Sponsored Programs.
CONFLICT OF INTEREST DISCLOSURE FORM
The purpose of this disclosure statement is for investigators at Alabama A&M University to
ensure that no unresolved conflict exists between their outside financial interests and their
commitment to their research or educational activities funded by Private and Federal
Agencies such as the National Science Foundation (NSF) and the National Institute of Food
and Agriculture (NIFA); and/or their proposed protocol for the use of human subjects in
research. This statement conforms to current Federal guidelines requiring limited and
targeted financial disclosure and review of the disclosure by a responsible University
representative. This statement discloses specific facts to help the appropriate Reviewer
determine if a conflict of interest exists so that the University can manage, reduce, or
eliminate the conflict.
Investigator's Full Name:
Employee ID Number:
Department/College:
Sponsoring Agency/Award #:
1. Are you or a member of your immediate family, a director, officer, partner, employee, or
agent, or in any managerial position in any business enterprise outside of the University
that might affect or be affected by your activities under the referenced proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet.)
No
2. Are you or your spouse or dependents the actual or beneficial owner of more than five
percent (5%) of the voting stock or controlling interest of any Business Enterprise in your
field of academic interest or specialization as it specifically relates to the referenced
proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet.)
No
3. Have you or your spouse or dependents collectively derived more than $10,000 in income within
the past year or do you or any member of your immediate family anticipate deriving collectively
income exceeding $10,000 per year from any business enterprise in your field of academic interest
or specialization as it specifically relates to the referenced proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet).
No
Page 1 of 2
