Fillable COE-COI Agreement Disclosure Form

Fill Online, Printable, Fillable, Blank COE-COI Agreement Disclosure Form Form

Use Fill to complete blank online ARKANSAS TECH UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COE-COI Agreement Disclosure Form

On average this form takes 2 minutes to complete

The COE-COI Agreement Disclosure Form form is 1 page long and contains:

  • 0 signatures
  • 4 check-boxes
  • 8 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Arkansas Tech University

BROWSE ARKANSAS TECH UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Arkansas Tech University Grants, Contracts and Sponsored Programs
Code of Ethics and Conflict of Interest Policy Agreement and Disclosure Form
Please check each box, indicating your agreement with each statement. If you do not agree, do not sign this form.
Return completed form to: Office of Sponsored Programs and University Initiatives, 1509 N Boulder Avenue, Admin Bldg, Room 207, Russellville, AR 72801
CONFLICT
Either check the box or explain any actual, potential, or perceived conflict that currently exists (or exists due
to a change in circumstance or a recent discovery). Attach separate sheet if needed and specify “continued on next page”.
VIOLATION
Either check the box or explain any violation of which you are aware or have become aware including
violations committed by other. Attach separate sheet if needed and specify “continued on next page”.
By signing this form, you attest that all information provided is accurate and complete and you acknowledge that all information not determined to be
exempt may be released by the University upon public request without further notice.
Printed Name
Date
Title
Department
Phone
Active Awards (Name and Index Code)
Administrative Review
Based upon the the self-disclosure as indicated on this form and any attachments:
No conflict or violation
Further action or
investigation required
Approved with conditions
Unacceptable conflict or
violation
_______________________________________________________________________________________ _________________________
GGSRC Chair Date
______________________________________________________________ ________________________________________________
Date of notification of GGSRC determination of status Method of notification of status
I have read, understand, and agree to abide by the Arkansas Tech University Code of Ethics and Conflict of Interest Policy for
Grants, Contracts and Sponsored Programs in all aspects of my involvement with grants, contracts, and sponsored programs.
I agree to disclose any circumstances or change in circumstances that could be construed as a conflict, perceived conflict, and/or
violation or potential violation of the Code of Ethics and Conflict of Interest Agreement during the term of my project and to
report any conflict, violation, or potential for violation, immediately upon discovery.
No conflict exists
No violation exists
Form updated 03-18-16
Print Form
Clear Form
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COE-COI Agreement Disclosure Form

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document