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

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

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Conflict of Interest Disclosure Details Form – Question F
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part F. Conflict of Commitment
The Conflict of Commitment policy requires disclosure of external activities if the time spent on combined external activities exceeds
40 days per academic year for 9 month appointments, or 50 days for 12 month appointments. For faculty with 9 month appointments
who receive external funding during the summer months (May 16-August 5), the 50 day limit applies. Individual schools and
departments may have additional disclosure requirements.
1. Number of days spent on external activities (to calculate your total number of days, accumulate half days into full days and
include preparation time and time spent traveling to and from external engagements):
Days Spent During Previous Academic Year: _________________
Days Spent During Current Academic Year (projected): _________________
Vanderbilt appointment type:
( ) 9 Month
( ) 12 Month
2. Types of external activity(ies) undertaken:
Business, philanthropic, community, or political activities
Clinical, research, or legal consultation
Educational Meetings and/or Conferences
Employment outside Vanderbilt University
Employment within Vanderbilt University but in addition to your primary employment
Expert witness testimony
Laboratory testing
Membership on advisory group and/or panel
Professional writing
Visiting lectureships
Scientific/Professional meetings or societies
Teaching
Other
Explain: _________________________________________________________________________
________________________________________________________________________________
3. Please list the businesses or organizations with whom you have significant commitments or external activities:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
4. Has your department chair or dean approved your outside activities in excess of the days allowed by the policy?
( ) Yes ( ) No
Approved b
y: ______________________________________
Date: ______________________________________________
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Conflict of Interest Disclosure Details Form Question F (Vanderbilt University)

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Completed 24 July 2020

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