Grants and Sponsored
Programs
CONFLICT OF INTEREST/FINANCIAL DISCLOSURE
Project Director/Principal Investigator
Department/Unit
School/College
Proposal Title
Proposal Submitted to
This proposal is for: Clinical Trial Research Non-Clinical Trial Research
Other
I understand that, for the purposes of this Form, "Significant Financial Interest" is defined as any interest valued
at greater than $10,000 and, irrespective of value, an equity or ownership interest of more than five percent in
any single entity held in aggregate by an Investigator and the Investigator's spouse and dependent children.
I understand that, for the purpose of this Form, "Significant Financial Interest" in Clinical Trial research is
defined as an interest regardless of financial value and, irrespective of value, an equity or ownership interest in
any single entity held in aggregate by an Investigator and the Investigator's spouse and dependent children.
I am disclosing the following Significant Financial Interest. Supporting documentation is attached in an envelope
marked confidential and addressed to the Grants & Sponsored Research Director. That documentation identifies
the entity/entities involved and the nature and amount of the interest:
Check one or more as applicable
Salary or other payment for services (e.g., consulting fees or honoraria)
Equity interests (e.g., stocks, stock options, or other ownership interests)
Intellectual property rights (e.g., patents, copyrights, and royalties from those rights)
Other financial interest of the Investigator that could possibly affect or be perceived to affect the results
of the research or other educational activities funded or proposed for funding such as business
ownership.
I further agree:
• To update this disclosure during the period of the award on an annual basis and To file a
disclosure on any new Significant Financial Interest that is obtained after submission of the
proposal and during the period of the award,
• To cooperate in the development of an appropriate management plan if the Director of Grants and
Sponsored Programs deems Conflict of Interest management to be necessary and,
