Investigator Disclosure Statement
Instructions: Please complete the form below and return to the Institutional Official, Scott Bateman. The completed form
may also be submitted via email to sbateman@sunypoly.edu. If any answer is checked “Yes” you will be contacted for
additional information.
Do you, your spouse or dependent child(ren) hold a position of management, such as board
member, director, officer, partner, trustee, employee or consultant with a profit or not-for-profit
entity?
If yes, what is that entity:
Do you, your spouse or dependent child(ren) have a financial interest in any publicly traded
entity where the value of any remuneration received from the entity in the twelve months
preceding this disclosure and/or the value of any equity in the entity as of the date of disclosure,
when aggregated exceeds $5,000?
Do you, your spouse or dependent child(ren) have a financial interest in any non-publicly traded
entity where the value of any remuneration received from the entity in the twelve months
preceding the disclosure, when aggregated, exceeds $5,000?
Do you, your spouse or dependent child(ren) hold any equity interest (e.g., stock, stock option,
or other ownership interest) in any non-publicly traded entity?
Have you, your spouse or dependent child(ren) received income from royalty or other forms of
payment, in the twelve months preceding the disclosure, when aggregated, exceeds $5,000? Do
not include intellectual property rights assigned to SUNY or the Research Foundation, or
agreements to share in royalties related to such rights.
Have you had travel sponsored or reimbursed for business reasons that cumulatively exceeds
$5,000? (other than from SUNY or The Research Foundation for SUNY)
Investigator Certification:
• I have read and understood the Investigator Financial Conflict of Interest Policy
• I agree to file a new or updated disclosure form if the answer to any of the above questions changes
• I certify that the answers are accurate and truthful to the best of my knowledge
Signature: Date: .
Questions concerning the policy or the annual disclosure should be addressed to Scott Bateman, Institutional Official.
Last updated 09/19/2017
