Fillable Disclosure Form (College of Wooster)

Fill Online, Printable, Fillable, Blank Disclosure Form (College of Wooster) Form

Use Fill to complete blank online COLLEGE OF WOOSTER pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Disclosure Form (College of Wooster)

On average this form takes 7 minutes to complete

The Disclosure Form (College of Wooster) form is 2 pages long and contains:

  • 2 signatures
  • 0 check-boxes
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for College of Wooster

BROWSE COLLEGE OF WOOSTER FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 2 August 24, 2012
THE COLLEGE OF WOOSTER
PHS/NIH Financial Conflict of Interest Disclosure Form
Name: ______________________________________________
Department: ____________________________________________________
Project Role: PI ___ Co-PI ____ Senior/Key Personnel ____ Consultant ____ Other ____
Project Title: _____________________________________________________________________
1. Do you or any member of your immediate family (spouse, partner, or dependent children) have any
Significant Financial Interests (SFI) in a Publicly-Traded Entity that might reasonably appear to be
related to your Institutional Responsibilities as defined in the PHS/NIH Conflict of Interest Policy?
(An SFI for publicly-traded entities exists if the value of any equity interest as of the date of
disclosure combined with any remuneration in the past 12 months exceeds $5,000.)
___ No
___ Yes Please attach a separate sheet with the name of the entity, nature of the interest, value, and
any documentation.
2. Do you or any member of your immediate family (spouse, partner, or dependent children) have any
Significant Financial Interests (SFI) in a Privately-Held Entity that might reasonably appear to be
related to your Institutional Responsibilities as defined in the PHS/NIH Conflict of Interest Policy?
(An SFI for privately-held entities exists if the value of any remuneration in the past 12 months
exceeds $5,000, or when the Investigator or immediate family holds any equity interest.)
___ No
___ Yes Please attach a separate sheet with the name of the entity, nature of the interest, value, and
any documentation.
3. Have you or any member of your immediate family (spouse, partner, or dependent children) received
any income related to intellectual property rights and interests that might reasonably appear to be
related to your Institutional Responsibilities as defined in the PHS/NIH Conflict of Interest Policy?
(Do not include any intellectual property that has been assigned to The College of Wooster.)
___ No
___ Yes Please attach a separate sheet with the name of the entity, nature of the interest, value, and
any documentation.
4. In the past 12 months have you undertaken any travel related to your Institutional Responsibilities as
defined in the PHS/NIH Conflict of Interest Policy that was either reimbursed or paid for by any
individual or entity other than a federal, state, or local government agency, an institution of higher
Page 2 of 2 August 24, 2012
education, an academic teaching hospital, a medical center, or a research institute that is affiliated
with an institution of higher education.
___ No
___ Yes Please attach a separate sheet with the purpose of the trip, name of the sponsor/organizer,
destination, duration, and approximate monetary value.
CERTIFICATION BY INVESTIGATOR
I have read and understand The College of Wooster PHS/NIH Conflict of Interest Policy.
To the best of my knowledge, I have made all required financial disclosures.
I agree to comply with any conditions or restrictions imposed by The College of Wooster for the
purpose of managing, reducing, or eliminating actual or potential conflicts of interest in connection
with this grant.
I agree to notify the Dean for Faculty Development of any modifications to the disclosures made on
this form.
Signature: __________________________________________ Date: ___________
Investigator
CERTIFICATION BY DEAN FOR FACULTY DEVELOPMENT
___ No financial conflict of interest appears to exist.
___ A financial conflict of interest may exist. My recommendation for management is attached.
Signature: __________________________________________ Date: ___________
Dean for Faculty Development
Please return the signed form to the Dean for Faculty Development.
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Disclosure Form (College of Wooster)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document