Fillable Conflict Interest Disclosure Form (Alabama A&M University)

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Conflict Interest Disclosure Form (Alabama A&M University)

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The Conflict Interest Disclosure Form (Alabama A&M University) form is 2 pages long and contains:

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  • 13 check-boxes
  • 9 other fields

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ALABAMA A&M UNIVERSITY
OFFICE OF SPONSORED PROGRAMS
Instructions:
This report is to be completed by
AAM
U Faculty/Staff
r
eceiving
research or teaching awards funded by a
Federal/State Agency or private company. Return the completed/signed form to the Office of Sponsored Programs.
CONFLICT OF INTEREST DISCLOSURE FORM
New Submission
Update
The purpose of this disclosure statement is for investigators at Alabama A&M University to
ensure that no unresolved conflict exists between their outside financial interests and their
commitment to their research or educational activities funded by Private and Federal
Agencies such as the National Science Foundation (NSF) and the National Institute of Food
and Agriculture (NIFA); and/or their proposed protocol for the use of human subjects in
research. This statement conforms to current Federal guidelines requiring limited and
targeted financial disclosure and review of the disclosure by a responsible University
representative. This statement discloses specific facts to help the appropriate Reviewer
determine if a conflict of interest exists so that the University can manage, reduce, or
eliminate the conflict.
Investigator's Full Name:
Employee ID Number:
Department/College:
Sponsoring Agency/Award #:
Title of Project:
1. Are you or a member of your immediate family, a director, officer, partner, employee, or
agent, or in any managerial position in any business enterprise outside of the University
that might affect or be affected by your activities under the referenced proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet.)
No
2. Are you or your spouse or dependents the actual or beneficial owner of more than five
percent (5%) of the voting stock or controlling interest of any Business Enterprise in your
field of academic interest or specialization as it specifically relates to the referenced
proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet.)
No
3. Have you or your spouse or dependents collectively derived more than $10,000 in income within
the past year or do you or any member of your immediate family anticipate deriving collectively
income exceeding $10,000 per year from any business enterprise in your field of academic interest
or specialization as it specifically relates to the referenced proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet).
No
Page 1 of 2
ALABAMA A&M UNIVERSITY
OFFICE OF SPONSORED PROGRAMS
Alabama A&M University, Office of Research and Sponsored Programs; Carnegie Building (2nd Floor)
Tel.: 256-372-5675; Fax: 256-372-5030; Email: OSP@aamu.edu
4. Do you or members of your immediate family have any other significant financial interest,
including salary or other payments for services, equity interest, and/or intellectual
property rights in any business enterprise in your field of academic interest or
specialization as it specifically relates to the referenced proposal or award?
Yes (If Yes, describe in detail the nature and extent of the affiliation on an attached sheet.)
No.
CERTIFICATION:
I have read and understand the Alabama A&M University Disclosure for Federal-funded
Projects; have made all financial disclosures required; and will comply with any conditions
or restrictions imposed to manage, reduce or eliminate actual or potential conflicts of interests.
Signature: Date:
REVIEWER'S CERTIFICATION:
I certify that to the best of my knowledge the person named above has disclosed all
reportable outside interests and activities, as related to the referenced proposal or award
sponsored by A Federal Agency or protocol submitted for IRB review. I further certify that
I have reviewed the disclosure and have determined:
no
conflict exists
any conflict has been managed, reduced, or eliminated
the conflict cannot be resolved, please notify the sponsoring agency. Additional
information is attached.
Signature:
Typed/Printed Name:
Title:
Date:
Page 2 of 2
AAMU Form-COI-1-2018
CONFLICT OF INTEREST DISCLOSURE FORM
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Conflict Interest Disclosure Form (Alabama A&M University)

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Completed 24 July 2020

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