Fillable Disclosure Form FCOI - Disclosure Form_FCOI

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Disclosure Form FCOI - Disclosure Form_FCOI

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8/2012&
&
Wilkes University Financial Disclosure Form
Due in the Sponsored Research Office no later than day of proposal submission.
See Wilkes University Conflict of Interest Policy for further detail.
Investigator Name:
Project Name:
Source of Funds:
Status: Current ☐ Pending ☐
Role in Project: PI ☐ Co-PI ☐ Senior/Key Personnel ☐ Consultant ☐ Unpaid Collaborator ☐
Other Investigator ☐ (as$defined$in$the$Policy)
In making the following certification and representations, please remember that all the following must
be included as significant financial interests:
• All financial interests pertaining to you personally;
• All pertaining to your spouse;
• All pertaining to a dependent child.
The following types of financial interests are excluded and should not be reported on this form as
significant financial interests:
• Salary, royalties, or other remuneration from Wilkes University;
• Income from investment vehicles such as mutual funds or retirement accounts, as long as you
do not directly control the investment decisions made in these vehicles;
• Income from seminars, lectures, or teaching engagements sponsored by, or service on advisory
committees or review panels for, or travel sponsored or reimbursed by any or all of the
following (U.S.-based entities only):
o Federal, State or local government agencies
o Institutions of higher education
o Academic teaching hospitals
o Medical centers
o Research institutes affiliated with institutions of higher education.
Check one of the following statements:
☐ I hereby certify that I have read the Conflict of Interest in Sponsored Research Policy, which is effective for
all Federal proposals submitted through the University. I certify to the best of my knowledge that neither I nor
my spouse or dependents hold any significant financial interests that would reasonably appear to be related to
my research, teaching and service responsibilities to Wilkes University.
☐ I (or my spouse and/or dependant child) have the following relationships, affiliations, activities, or interests
which constitute significant financial interests under the Wilkes University Conflict of Interest policy (see
following pages):
_____________________________ ___________
Signature Date
Page&2&of&4&
&
Investigator&Initials:&____& Date:&___________&
2&
Publicly Traded Entities
Instructions: Copy as many times as needed for all publicly-traded entities. Do not include any
company for which subtotal of all financial interests < $5,000
Entity Name
Interests Pertaining
to (check all that
apply):
Type of Interest
Value of Interest
Combined Value of
Equity and Any
Compensation
☐ Self
☐ Spouse
☐ Dependent Child
☐ Equity
☐ Compensation
Equity Value
$ _______________
and/or
Compensation over last
12 months
$_________________
☐ Self
☐ Spouse
☐ Dependent Child
☐ Equity
☐ Compensation
Current Mkt. Value
$ _______________
and/or
Compensation over last
12 months
$_________________
☐ Self
☐ Spouse
☐ Dependent Child
☐ Equity
☐ Compensation
Current Mkt. Value
$ _______________
and/or
Compensation over last
12 months
$_________________
Non-Publicly Traded Entities (Equity Interests)
Instructions: List all non-publicly traded entities in which you, your spouse and/or dependent child
hold an equity interest, regardless of dollar value. Add rows if needed. Estimated $ value and %
ownership columns are optional, but the University reserves the right to request this information
during the Conflict of Interest determination process if these are left blank.
Entity Name
Interests Pertaining
to (check all that
apply):
Entity Business
Type
% Ownership
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
Page&3&of&4&
&
Investigator&Initials:&____& Date:&___________&
3&
Non-Publicly Traded Entities (Compensation)
Instructions: List all non-publicly traded entities from which you, your spouse and/or dependent child
have received compensation of $5,000 or more in the last 12 calendar months. All columns must be
completed in full. Add rows if necessary.
Entity Name
Interests Pertaining
to (check all that
apply):
Position or
Relationship
Entity Business
Type
Total
Compensation in $
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
Compensation for Intellectual Property Rights
Instructions: This does not include any payment from Wilkes University for intellectual property
assigned to the University in conformance with the College’s Intellectual Property policy. List all
entities other than Wilkes University from which you, your spouse and/or your dependent child have
received payment for intellectual property rights (e.g. royalties, licensing fees, etc.) in the last 12
calendar months. Add rows if necessary.
Entity Name
Interests Pertaining
to (check all that
apply):
Description of Intellectual Property
Total
Compensation in $
☐ Self
☐ Spouse
☐ Dependent Child
☐ Self
☐ Spouse
☐ Dependent Child
Page&4&of&4&
&
Investigator&Initials:&____& Date:&___________&
4&
Sponsored or Reimbursed Travel
Instructions: List any instance of travel from the last 12 calendar months which was either sponsored
or reimbursed by an entity other than Wilkes University or those types of entities excluded from
disclosure on page 1. Include any instance where reimbursement was made by Wilkes University from
a fund account sponsored by a non-excluded entity. Add rows if needed. Estimated cost column is
optional, but may be requested upon review of information provided.
Traveler (check
all that apply)
Destination
Dates of Travel
Purpose of
Travel
Sponsor Name
or
Reimbursement
Source
Estimated
costs in $
☐ Self
☐ Spouse
☐ Dependent
Child
☐ Self
☐ Spouse
☐ Dependent
Child
☐ Self
☐ Spouse
☐ Dependent
Child
☐ Self
☐ Spouse
☐ Dependent
Child
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Completed 19 November 2019

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