Conflict of Interest Disclosure Form – Staff
Name: ________________________________________ Job Title: ________________________________
(PLEASE PRINT CLEARLY)
Department: __________________________________________________________________________
A. Business Relationships and Licensing Agreements
Do you or a family member have any business relationship (including licensing agreements) with a business that (a) has a contractual
relationship with Vanderbilt, (b) provides goods or services to Vanderbilt, (c) sponsors or is involved in research activities at Vanderbilt, (d)
receives referrals from Vanderbilt, or (e) pays royalties directly to you (even royalties paid through Vanderbilt)?
Ο No Ο Yes
B. Family Members Working Together at Vanderbilt
Do you work in the same area or department as a family member or have you been involved in the hiring, supervision, or review of the work
of a member of your family working at Vanderbilt?
Ο No Ο Yes
C. Gifts for Personal Use
Have you (as an individual or on behalf of your department) or a family member accepted gratuities, gifts, or special favors from someone (or
an entity) who is doing business with or proposing to do business with the University?
Ο No Ο Yes
D. Outside Jobs/Activities or Other Relationships (If Healthcare-related, please also answer Question G.)
Do you have a job outside of Vanderbilt, or are you or a family member involved in any other activity or other relationship that creates a
conflict of interest/commitment or the appearance of a conflict of interest/commitment under the Vanderbilt University Conflict of Interest and
Commitment Policy?
Ο No Ο Yes
E. Legal Proceedings
Have you been involved in any criminal proceedings (arrest or conviction) as a defendant (other than a minor traffic offense) for which you
have not created a previous disclosure or have you been debarred, suspended, or otherwise excluded by a duly authorized regulatory agency
or had a transaction with any such agency terminated for any reason?
Ο No Ο Yes
F. Overlapping Time Commitments
Do you have more than one job at Vanderbilt or activities outside of work with overlapping time commitments with your job at Vanderbilt?
Ο No Ο Yes
G. Healthcare Industry-Sponsored Activities
Have you accepted payments from any Healthcare Industry vendor i.e. suppliers of pharmaceuticals, medical equipment and devices or
medical services?
Ο No Ο Yes
H. Research and Financial Interests
Do you engage in sponsored research in your position at Vanderbilt and you or your family member have any of the following (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, or (d) travel reimbursed or paid and not funded
through the University?
Ο No Ο Yes
Acknowledgements (Please read each statement and check-off each box.)
Policy - I have reviewed the Vanderbilt University Conflict of Interest Policy and the Policy on Technology and Literary and Artistic Works at
https://www.vanderbilt.edu/generalcounsel/docs/coifiles/CurrentCOIPolicy.pdf and https://cttc.co/inventors/policies/vu-technology-policy
, and I agree to
comply with their provisions. The information I have provided is accurate and not false, erroneous, misleading, or incomplete. I will file an updated form if
changes occur that may either (a) give rise to a new conflict of interest or commitment or (b) eliminate a conflict previously disclosed.
Official Disclosure - As a member of the Vanderbilt Community, I understand that this online disclosure form is the only authorized means by which I may
make, as required by institutional policy, disclosures regarding outside activities and financial interests that create or have the appearance of creating
conflicts of interest. Although I may elect to seek guidance by other means, I understand that no such action can result in approval of an outside activity or
financial interest. I understand that authorized approval for outside activities and financial interests can only be granted through use of the online disclosure
tool.
Standards of Conduct - Annual Review & Disclosure - I acknowledge that I have reviewed Vanderbilt University's Standards of Conduct
Standards of
Conduct and I understand that I am responsible for knowing and following the Standards of Conduct, and all relevant laws, rules and regulations.
Confidential Helpline - I understand that if I have compliance-related concerns, questions or issues to report, I can call the 24-hour anonymous Confidential
Compliance Helpline
.
Certification of Completion of Training. I hereby certify that either I have no research funding source that follows conflict of interest regulations
promulgated by the Public Health Service at 42 CFR 50.605, or that I have completed the required training for PHS investigators at the following link:
https://www.vanderbilt.edu/generalcounsel/docs/coifiles/fcoi_PHS_training_updated_2.27.19.pdf
Assignments - In accordance with the Technology Policy, I hereby assign to Vanderbilt all right, title and interest I now have or will have in the future in
and to any patent, copyright and other intellectual property right covering any invention, software or other Technology created or authored by me while
employed at Vanderbilt University. (Please check the box to indicate your agreement.) PLEASE SEE FURTHER DETAILS ON THE BACK OF THIS FORM.
Signature: _________________________________________________ Date: ______________________________
Instructions: Mark your answer for EACH question below. If your answer to any question is YES, you and/or your manager will be contacted for more
information about possible conflicts. This form may also be completed online at:
https://admin.app.vanderbilt.edu/coi/
