Fillable Conflict of Interest Disclosure Details Form Question A (Vanderbilt University)

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Conflict of Interest Disclosure Details Form Question A (Vanderbilt University)

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COI Disclosure Details Form – Question A 1
Conflict of Interest Disclosure Details Form – Question A
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
A. Business
Relationships
and Licensing Agreements
Please disclose the details of your potential conflict for this circumstance. If you have more than one Business Relationship or
Licensing Agreement to disclose, you will need to add additional disclosure details from the disclosure details summary page.
General Business Information
Name of Business: ____________________________________________________________________________
1. Briefly describe the business relationship, including your or your family member’s relationship with the entity and any business,
research or licensing activity:
Categorize the business's relationship with Vanderbilt:
Supplier of goods and/or services
Consultant
or advisor
Research activities
Business or clinical referrals
Licensing agreement
Equity holding
Business provides funds and/or gifts to your unit (department, division, or center) in support of education, travel,
research, or other activities. Please specify the amount and purpose of any funds or gifts received (describe):
Other contractual or business relationship (describe):
2. Are you or your family member receiving any type of compensation (outside of your Vanderbilt salary) for this work?
( ) Yes ( ) No
If YES, what form does this compensation take? (i.e. salary, royalties, equity) ____________________________
3. Do your job responsibilities at Vanderbilt involve this business?
( ) Yes ( ) No
If YES, describe your involvement:
COI Disclosure Details Form – Question A 2
4. Does someone at Vanderbilt oversee and approve the business relationship:
( ) Yes ( ) No
4a. Who at Vanderbilt oversees and approves the relationship with this business?
Name: ______________________________________________________
Title: _______________________________________________________
Department: _________________________________________________
Phone:______________________________________________________
4b.
Do you report directly to this
person?
( ) Yes ( ) No
5. Have you used Vanderbilt's name, resources,
or confidential information in connection with this business?
( ) Yes ( ) No
If YES, describe the Vanderbilt resources
used:
Significant Financial Interest
6. Please check one of the following statements:
( ) This business is a publicly traded company (Please proceed to Question 6a)
( ) This business is a non-publicly traded company (Please proceed to Question 6b)
6a. Do you or a family member receive annual income in excess of $5,000 and/or own equity holdings greater in value
than $5,000?
( ) Yes (please answer 6a1, 6a2, & 6a3 below)
( ) No (proceed to Question 7)
6a1. Please mark all of the following criteria for "Significant Financial Interest" which apply to your relationship
with this business.
( )
Annual income in excess of $5,000
( )
Equity holdings greater in value than $5,000
6a2. Indicate what safeguards are currently in place or that you propose to prevent your activities from creating
an inappropriate conflict of interest:
6a3. What is the total value of your relationship (including income and equity holdings)?
( )
$0 - $4,999
( )
$5,000 - $9,999
( )
$10,000 - $19,999
( )
$20,000 - $39,999
( )
$40,000 - $59,999
( )
$60,000 - $79,999
( )
$80,000 - $99,999
( )
$100,000 - $149,999
( )
$150,000 - $199,999
( )
$200,000 and over. Please give approximate amount: _____________________.
COI Disclosure Details Form – Question A 3
(Please fill in 6b-6b3 if you selected “This business is a non-publicly traded company
” above.)
6b. Do you or a family member receive annual income in excess of $5,000 and/or own equity holdings of any amount in
this business?
( ) Yes (please answer 6b1, 6b2, & 6b3 below)
( ) No (proceed to Question 7)
6b1. Please mark all of the following criteria for "Significant Financial Interest" which apply to your relationship with
this business.
( ) Annual income in excess of $5,000
( )
Equity holdings (in any amount including those with no current value)
6b2. Indicate what safeguards are currently in place or that you propose to prevent your activities from creating an
inappropriate conflict of interest:
6b3. What is the total value of your relationship (including income and equity holdings)?
( )
Value of equity holding cannot be readily determined.
( )
$0 - $4,999
( )
$5,000 - $9,999
( )
$10,000 - $19,999
( )
$20,000 - $39,999
( )
$40,000 - $59,999
( )
$60,000 - $79,999
( )
$80,000 - $99,999
( )
$100,000 - $149,999
( )
$150,000 - $199,999
( )
$200,000 and over. Please give approximate amount: _____________________.
Faculty or Staff Involvement
7. Do faculty members or staff at Vanderbilt who report to you participate in activities at Vanderbilt University related to this
business?
( ) Yes ( ) No
If Yes, Please provide the name(s) of the faculty/staff member and the nature of their involvement:
8. Are you or a family member in a position to influence agreements or contracts made between Vanderbilt and the business (other
than research grants and contracts)?
( ) Yes ( ) No
If Yes, Please explain:
9. Please indicate the number of days YOU spent on behalf of this business in the past academic year: _______________
10. How many days you expect to spend on behalf of this business in the current academic year: ____________________
COI Disclosure Details Form – Question A 4
Student Involvement
Involvement of students and postdoctoral fellows in research relating to commercial ventures may be beneficial and is not
necessarily discouraged. However precautions must be taken to avoid their participation in situations that may be detrimental to
the progress of their training or their professional careers.
11. Either currently or in the past year, have you supervised or otherwise allowed undergraduate, graduate, or professional
students, post-doctoral fellows, or other trainees to participate in activities related to this business?
( ) Yes ( ) No
If Yes, describe below and include what type of students are involved (i.e. fellows, graduate, medical, undergraduate):
11a. Have you received the approval of the Academic Dean of the college?
( ) Yes ( ) No
11b. What safeguards are currently in place or will you take to prevent your relationship with the business from affecting
your academic responsibilities as a faculty member to the students, fellows or trainees?
Research Support and Activities
12. Do you or faculty members or other staff who report to you receive research support or support for other academic activities
from this business?
( ) Yes ( ) No
If Yes, Describe:
12a. Is this support made known to and is all of this support administered through the Office of Research or the Division
of Sponsored Research?
( ) Yes
If Yes, Please indicate the office(s) you have notified:
( ) Office of Research
( ) Division of Sponsored Research
( ) No
If No, Please explain:
12b. Does this research support involve clinical research with human subjects?
( ) No
( ) Yes
If Yes, Will these research studies be conducted at Vanderbilt?
( ) No
( ) Yes (If yes, answer i and ii below)
COI Disclosure Details Form – Question A 5
i, Does the I.R.B. Application indicate the existence of a potential conflict of interest?
( ) Yes
( ) No
If No, Please Explain:
ii. Does the Consent Form include a statement disclosing the investigator’s potential conflict of interest?
( ) Yes
( ) No
If No, Please Explain:
12c. Are the results of your research made available to this business prior to publication or other public presentation?
( ) No
( ) Yes
If Yes, Have these arrangements been reviewed and approved?
( ) Yes
If Yes, By whom have they been reviewed and approved?
( ) Office of Research
( ) Division of Sponsored Research
( ) Office of Technology Transfer
( ) No
If No, Please explain reason for no review and approval:
Disclosure
13. Do you disclose your relationship with this business in all publications and presentations of relevant materials and to students
involved in activities related to this business?
( ) Yes ( ) No
If No, Please explain:
Safeguards
Indicate what safeguards are currently in place or that you propose to prevent your activities from creating an
inappropriate conflict of interest.
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Completed 24 July 2020

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