EXHIBIT E
Significant Financial Interest (SFI) Disclosure Form
RTI International is a trade name of Research Triangle Institute
Financial Conflicts of Interest (FCOI) Significant Financial Disclosure (SFI) form 10162012a, pg. 2
Part 2. SOURCES OF EARNED INCOME AND TRAVEL
For you, your spouse and your dependent children, identify sources of earned income which generated over $5,000 in income as of
the date of the disclosure. Sources of Earned Income include salaries received from other than your current employer, fees,
honoraria and travel. Refer to the definitions below Part 3 for additional information.
I do not have any sources of earned income or travel requiring disclosure. CONTINUE TO PART 3 OF THIS FORM.
I disclose the following sources of earned income or travel. After completing this section, CONTINUE TO PART 3 OF THIS
Approximate value of the financial interest
Name of Earned Income Source(s)
(Employee, Spouse,
Dependent Child, or
combination)
(salary,
consulting fees,
honoraria, etc.)
increments of
$5,000 (e.g.
$5,000 to
$100,000
Increments of
$20,000
above by
increments of
$50,000
For travel disclosures, please provide the following additional detail
UPON COMPLETION OF THIS DISCLOSURE FORM, PLEASE EMAIL IT AS AN ATTACHMENT TO SFIDisclosures@rti.org.
Submission of this form confirms your belief that all information provided is true, complete and accurate to the best
SFI Disclosure Form Definitions as provided by the Office of Extramural Research of the National Institutes of Health
Significant Financial Interest (SFI) is defined by the regulation as:
I. A financial interest consisting of one or more of the following interests of the investigator (and those of the investigator’s spouse and dependent children)
that reasonably appears to be related to the Investigator’s institutional responsibilities:
a. With regard to any publicly traded entity, an SFI exists if the value of any remuneration received from the entity in the 12 months preceding the
disclosure and the value of any equity interest in the entity as of the date of the disclosure, when aggregated, exceeds $5,000. For purposes of
this definition, remuneration includes salary and payment for services not otherwise identified as salary (e.g., consulting fees, honoraria, paid
authorship); equity interest includes any stock, stock options, or other ownership interest, as determined through reference to public prices or
other reasonable measures of fair market value;
b. With regard to any non-publicly traded entity, an SFI exists if the value of any remuneration received from the entity in the 12 months
preceding the disclosure, when aggregated, exceeds $5,000, or when the Investigator (or the Investigator’s spouse or dependent children) hold
any equity interest (e.g., stock, stock options, or other ownership interest); or
c. Intellectual property rights and interests (e.g., patents, copyrights), upon receipt of income related to such rights and interests.
II. Investigators also must disclose the occurrence of any reimburse or sponsored travel (i.e., that which is paid on behalf of the Investigator and not
reimbursed to the Investigator so that the exact monetary value may not be readily available), related to their institutional responsibilities; provided,
however, that this disclosure requirement does not apply to travel that is reimbursed or 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. The Investigator’s disclosure will include the identity of the sponsor/organizer, the destination, and the duration.
The RTI Privacy Officer can request additional information from the Investigator in order to determine whether the travel constitutes an FCOI with the
PHS-funded research.
III. The term SFI does not include the following types of financial interests:
a. Salary, royalties, or other remuneration paid by the Institution (i.e., Investigator’s employer) to the Investigator if the Investigator is currently
employed by the Institution, including intellectual property rights assigned to the Institution and agreements to share in royalties related to
such rights;
b. Any ownership interest in the Institution held by the Investigator, if the Institution is a commercial or for-profit organization;
