DISCLOSING SIGNIFICANT FINANCIAL INTERESTS
SUBRECIPIENT INVESTIGATORS on PHS or NSF FUNDED PROJECTS
The University of Northern Colorado’s Financial Conflict of Interest Policy is found in the University Regulations Article 3,
Part 4, Section 3-3-402(1), and the implementing procedures are found at http://www.unco.edu/osp/policies/fcoiproc.pdf.
Please review those documents and read the following guidelines before completing the disclosure form.
Disclosure Requirements: You have been identified as a subrecipient investigator subject to the University of Northern
Colorado’s (UNC) Financial Conflict of Interest policy. As an investigator on a proposed Public Health Service or National
Science Foundation project, please disclose your significant financial interests (SFI) aggregated with those of your spouse
and dependent children, on the attached disclosure form. These disclosure requirements are in compliance with PHS
regulations 42 CFR Part 50 Subpart F or Chapter IV of the NSF Award and Administration Guide, as applicable.
Disclosures must be made:
o For PHS and NSF funded projects an initial disclosure must be provided prior to UNC submitting the proposal.
o For PHS and NSF funded projects an update for disclosing new significant financial interests must be provided
within 30 days of discovering or acquiring any new financial interest (including those that may arise between the
time the proposal is submitted and the time a subaward is made)
o For PHS funded projects an annual update must be provided during the period of the subaward. Annual
disclosures are due between November 1 and November 31 regardless of when you made your initial disclosure or
disclosed new SFIs.
NOTE: UNC will not submit a proposal until disclosures from all investigators on the project have been received.
Training Requirement for PHS funded projects: If a proposed PHS funded project is awarded, you are required to
complete conflict of interest training before engaging in work related to the PHS funded award and again every four years
during the period of the subaward. The required training is available on-line through the Collaborative Institutional
Training Initiative (CITI). To access CITI, follow the directions at: http://www.unco.edu/osp/ethics/citi.html; and when on
the CITI website, complete the Conflict of Interest modules. You will need to affiliate your training with the University of
Northern Colorado so that we receive your training certification.
If you have completed the CITI Conflict of Interest training within the past four years, you may provide a copy of your
CITI Completion Report with your significant financial interests disclosure form in lieu of taking the training again at this
time.
DISCLOSURE DEFINITIONS
o Remuneration includes all salary and any payment for services not otherwise identified as salary, such as
consulting fees, honoraria, and paid authorships.
o Equity interest includes any stock, stock option, or other ownership interest with the value determined through
public prices or other reasonable measures of fair market value.
DISCLOSURE EXCEPTIONS DO NOT INCLUDE the following when disclosing financial interests:
o Salary, royalties, or other remuneration paid by the Subrecipient if you (or your spouse or dependent children, as
applicable) are currently employed or otherwise appointed by the Subrecipient;
o Income related to intellectual property rights assigned to the Subrecipient or to agreements to share in royalties
related to such rights;
o Income from investment vehicles such as mutual funds and retirement accounts for which you, your spouse and
dependent children do not directly control the investment decisions made in such vehicles
o Income from seminars, lectures, or teaching engagements sponsored by a Federal, state, or local government
agency, an institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a
medical center, or a research institute that is affiliated with an institution of higher education as defined at 20
U.S.C. 1001(a)
o Income from service on advisory committees or review panels for a Federal, state, or local government agency, an
institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or
a research institute that is affiliated with an institution of higher education as defined at 20 U.S.C. 1001(a)
You need to report only those Significant Financial Interests that are, or could be perceived to be, directly related to
your employment responsibilities or to the work you will be performing in collaboration with UNC on the identified
project.
Please address questions regarding your disclosure to Sherry May at 970-351-19102 or sherry.may@unco.edu.
DISCLOSURE DETAILS
When you complete the disclosure form (last page of this document), if you check to indicate that you are disclosing any
significant financial interests, as listed in numbers 1 through 6, attach additional pages to your disclosure form to provide
details as listed below.
When responding, remember that you are disclosing financial interests that are aggregated for yourself, your spouse, and
your dependent children.
1. If you check #1 on the disclosure form, provide the following for each publicly traded entity involved:
o The name of the publicly traded entity
o The combined value of remuneration received and equity interest
o An explanation of how you determined the value of your equity interest
o An explanation of how this financial interest could or could not appear to be related to your employment
responsibilities and to the work you will be conducting on the proposed project with UNC
2. If you checked #2 on the disclosure form, provide the following for each non-publicly traded entity involved:
o The name of the non-publicly traded entity
o Whether the financial interest was remuneration or equity interest
o If it was remuneration, the value of that received
o An explanation of how you determined the value of your equity interest
o An explanation of how this financial interest could or could not appear to be related employment responsibilities
and to the work you will be conducting on the proposed project with UNC
3. If you check #3 on the disclosure form, provide a list of the intellectual property (copyrights, patents, etc.) and the
value of income received from each
4. If you check #4 on the disclosure form, provide the following for each entity involved:
o The name of the entity
o The value of the equity interest
o The percentage of ownership your interest represents in that entity
o An explanation of how you determined the value of the equity interest
o An explanation of how this financial interest could or could not appear to be related to your employment
responsibilities or to the work you will be conducting on the proposed project with UNC
5. If you check #6 on the disclosure form, provide the following for each instance of such travel:
o The purpose of the trip
o The identity of the sponsor or organizer of the travel
o The destination
o The duration of the travel
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Please do not submit these guidelines with your disclosure form.
It is only the form on the next page that must be provided to the University of Northern Colorado.
Signed, completed disclosure forms are to be returned with your institution’s Subrecipient Compliance Form.
Mail hard copies to:
University of Northern Colorado
Office of Sponsored Programs
Campus Box #143
Greeley, CO 80639
Attention: Sherry May
Or email to sherry.may@unco.edu
Or fax to (970) 351-1934
NOTE: Compliance and disclosure forms, including those sent by email or facsimile, must have signatures.
University of Northern Colorado
Subrecipient Disclosure of Significant Financial Interests
Name: Role on Subaward:
Email: Telephone:
Subrecipient Institution/Organization:
Mailing Address:
University of Northern Colorado PI/PD:
Title of UNC Project:
Check one: Initial disclosure Update disclosing new significant financial interests Required annual update
Check all of the following that represent your significant financial interests when aggregated with those of your
spouse, and dependent children.
1. Remuneration received from any publicly traded entity during the 12 months preceding this disclosure,
plus equity interest in that entity as of the date of this disclosure, the combined value of which exceeds
$5,000.
2. Remuneration received during the 12 months preceding this disclosure from any non-publicly traded
entity that exceeds $5,000 in value, or any equity interest in that entity as of the date of this disclosure
3. Income related to intellectual property rights and interests.
4. Equity interest in any single entity, the value of which exceeds $10,000 and represents more than a 5%
ownership as of the date of this disclosure
5. Travel related to my work on this project that was paid on my behalf or reimbursed to me, excluding
such travel that was paid by a Federal, state, or local government agency, an institution of higher
education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research
institute that is affiliated with an institution of higher education as defined at 20 U.S.C. 1001(a).
Details of the significant financial interests I have identified above are provided on attached pages.
I have no significant financial interests to disclose at this time.
INVESTIGATOR CERTIFICATION
I have read the University of Northern Colorado policy on Financial Conflict of Interest Pertaining to Sponsored
Programs, and understand my responsibilities thereunder. I agree to comply with conditions or restrictions that
may be imposed by UNC to manage my real or perceived financial conflicts of interest. I understand that I may
be asked to provide additional information when needed to determine if a financial conflict of interest exists.
I certify that to the best of my knowledge, the information provided here is a complete and accurate disclosure
of my significant financial interests as of the date of my signature below.
NOTE: The signature must be dated
Signature Date
All information provided and records related to this disclosure will be held in confidence to the extent permitted by law and in
accordance with UNC’s Policy on Financial Conflict of Interest Pertaining to Sponsored Programs and the Implementing Procedures.
Approved: Date: 05.2016
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