MONTANA TECHNOLOGICAL UNIVERSITY
Conflict of Interest Disclosure Statement and Certification
Complete the following form and submit it to your academic dean, director or executive officer on or before September 30
th
annually. For questions concerning the information required by this form contact the Office of Research.
Name: _____________________________________________________ Dept: _____________________________________
Position: ______________________________________________________ Phone #: __________________________________
Certification
By signing below you are certifying:
1. You h
ave read and understand Montana Tech’s “Conflict of Interest and Financial Disclosure” policy, as revised 6/8/2015.
2. You eit
he
r (check one box below):
a. :
Have no relationships or financial interests that are or could be perceived to be in conflict with your duties and
responsibilities to Montana Tech in sponsored research, in professional activities, or in family relationships
(nepotism).
OR
b. :
Have potential conflicts of interest as described in the statement below.
Disclosure Statement
I am d
isclosing the following significant financial interests or relationships (check all applicable interests and relationships), and I attach supporting
documentation that identifies the person, business enterprise or entity involved and the nature and amount of the interest and/or relationship:
Salary or other payment for services (e.g., consulting fees or honoraria) from any business entity that exceeded $5,000 during
the past 12 months.
Equity interests (e.g., stocks, stock options, or other ownership interests) in any publicly traded entity valued in excess of
$5,000 or greater than 5% ownership, or a combination of stock and income from that entity that exceeds $5,000/year. Any
ownership interest in a non-publicly-traded entity (such as a start-up company), regardless of its value.
Any relationship with an entity that would be affected by the employee’s research, or could be directly affected by a decision
the employee participates in at Montana Tech or involving Montana Tech funds.
Income from intellectual property rights (e.g., patents, copyrights, and royalties) paid by any source other than Montana Tech.
Any travel which is paid for or reimbursed by another organization and which is related to my Institutional Responsibilities;
provided however, that the disclosure requirement does not apply to travel that is reimbursed by a Federal, State, or local
government agency, or an institution of higher education.
Service as an advisor, consultant, or in another capacity with a public or private agency that grants money to Montana Tech or
decides policy for grants that could materially affect Montana Tech’s eligibility for funds from that agency.
Management or consulting position, board membership, or role as agent or representative of or participant in the day-to-day
operations of a commercial enterprise active in field(s) related to the employee’s Montana Tech responsibilities.
Supervision and/or authority to influence the hiring, salary, promotion, retention, or tenure or other employment benefits of an
immediate family member or a close business associate or employee of an entity in which the employee or family member has
an ownership interest.
Any relationship of yours or a family member's with an entity that is or could become a vendor or supplier to Montana Tech.
Further I agree:
To update
this disclosure on an annual basis and any time new reportable significant financial interests are obtained.
To cooperate in the development of a Conflict Management Plan, if determined necessary by the University.
Meet privately with the Research Office if applying for or receiving funding from the Public Health System (e.g. NIH) and comply with additional
requirements mandated by PHS.
To comply with any conditions or restrictions imposed by the Montana Tech to manage, reduce, or eliminate actual or potential conflicts of
interest or forfeit the award, if applicable.
Date: _______________________
Date:
_______________________
Signed: _______________________________________________________________
(Original signature only)
Reviewed by Supervisor: ________________________________________________
Reviewed by Vice Chancellor for Research: _________________________________
Date: ______________________
_
Disposition:
No Conflict See Conflict Management Plan Other: ______________
COI - 8/30/19
