Fillable Additional Key Personnel Page Signature Coi 3 2020 Final Correction 2 Additional Key Personnel Page

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Additional Key Personnel Page Signature Coi 3 2020 Final Correction 2 Additional Key Personnel Page

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Form Date: 03/2020
Additional Key Personnel
List and briefly describe the role of all personnel in the study and disclose any potential and/or real financial conflict of interest.
Please see FCOI section of the Protocol Summary Form for directions.
If any response below is “yes,” there must be a “Financial Conflict of Interest Detailed Disclosure Form” submitted directly to the
Financial Conflict of Interest Committee prior to the time of this submission and then annually or when changes occur.
If any response below is “yes,” the FCOI committee communication must be included with this submission. If this communication is not
included, then the protocol cannot be submitted to the IRB.
Key personnel are persons engaged in the collection of data or have access to data through intervention or interaction with the participant,
including the consent process, or have access to the participant’s identifiable private information. This may include collaborators, fellows,
residents, research assistants, research nurses, Co-investigators, etc. Co-PIs are not allowed— only Co-Investigators
Name
Division/Dept
Research Role
E-Mail Address
a.
Do you, your spouse or domestic partner, or any of your dependent children have a potential and/or real financial conflict
of interest with the sponsor of this project, including all secondary sources? Date Signed & COI Disclosure:
NO YES—see additional directions above.
Signature:
b.
Do you, your spouse or domestic partner, or any of your dependent children have a potential and/or real financial conflict
of interest with the sponsor of this project, including all secondary sources? Date Signed & COI Disclosure:
NO YES—see additional directions above.
Signature:
c.
Do you, your spouse or domestic partner, or any of your dependent children have a potential and/or real financial conflict
of interest with the sponsor of this project, including all secondary sources? Date Signed & COI Disclosure:
NO YES—see additional directions above.
Signature:
d.
Do you, your spouse or domestic partner, or any of your dependent children have a potential and/or real financial conflict
of interest with the sponsor of this project, including all secondary sources? Date Signed & COI Disclosure:
NO YES—see additional directions above.
Signature:
e.
Do you, your spouse or domestic partner, or any of your dependent children have a potential and/or real financial conflict
of interest with the sponsor of this project, including all secondary sources? Date Signed & COI Disclosure:
NO YES—see additional directions above.
Signature:
Principal Investigator:
Study Title:
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Additional Key Personnel Page Signature Coi 3 2020 Final Correction 2 Additional Key Personnel Page

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Completed 12 May 2020

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