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

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

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Conflict of Interest Disclosure Details Form – Question H
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part H. Research and Financial Interests
Please disclose the details of your potential conflict for this circumstance. If you have more than one sponsored travel to disclose,
you will need to add additional Disclosure Details sheets.
1. Is your position funded by PHS (or NIH) or any funding source that follows PHS regulations regarding conflict of interest?
( ) Yes ( ) No
1a. Are you a PHS funded employee who has had travel expenses (including transportation, accommodations, meals and
leisure activities) related to your institutional responsibilities and paid by a third party (outside of Vanderbilt) for yourself or
a family member for any purpose?
( ) Yes ( ) No
1a1. What group, organization, or person sponsored the travel?
_______________________________________________________________________________
_______________________________________________________________________________
1a2. What was the purpose of the travel?
_______________________________________________________________________________
______________________________________________________________________________
1a3. Where was the destination?
______________________________________________________________________________
1a4. What was the duration of the trip?
______________________________________________________________________________
1a5. Please list any special services provided (including first class travel, luxury accommodations, and leisure
activities).
______________________________________________________________________________
_______________________________________________________________________________
1a6. Were the travel and accommodations provided reasonable, customary, and similar to what would be acceptable
under Vanderbilt travel policies for travel expenses paid by Vanderbilt?
( ) Yes ( ) No
1a7. Please list all anticipated travel not reimbursed by Vanderbilt (and not within other exceptions) for the next year:
2. Do you (or a family member) have any of the following that are related to your institutional responsibilities: (a) payments
from an outside entity or foreign government greater than $5,000 in the past year, (b) any equity in a non-publicly traded
entity, (c) equity in a publicly traded entity valued greater than $5,000?
( ) Yes ( ) No
2a. Please check one of the following statements:
( ) This business is a publicly traded entity or foreign government (Please proceed to Question 2a1)
( ) This business is a non-publicly traded entity(Please proceed to Question 2a2)
2a1. 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 2a1a, 2a1b, & 2a1c below)
( ) No
2a1a. 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
2a1b. Please provide the name of the entity, the reason for your financial interest with the entity, and indicate
what safeguards are currently in place or that you propose to prevent your activities from creating an
inappropriate conflict of interest:
2a1c. 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: ______________
This business is a non-publicly traded entity. (Please fill in this section if you selected “This business is a non-publicly traded
entity” above.)
2a2. 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 2a2a, 2a2b, & 2a2c below)
( ) No
2a2a. 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)
2a2b. Please provide the name of the entity, the reason for your financial interest with the entity, and indicate
what safeguards are currently in place or that you propose to prevent your activities from creating an
inappropriate conflict of interest:
2a2c. What is the total amount received and/or value of equity holding?
( )
$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: ______________
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Conflict of Interest Disclosure Details Form Question H (Vanderbilt University)

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Completed 24 July 2020

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