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:
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.
9. 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
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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Conflict of Interest Disclosure Details Form Question A (Vanderbilt University)

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Completed 24 July 2020

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