Fillable Fcoi Disclosure V2 2

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Fcoi Disclosure V2 2

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  • 16 check-boxes
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File type: PDF

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CONFIDENTIAL
Financial Conflict of
Interest Disclosure Form
To be used if "yes" was selected on the Significant Financial Interest Form
Name:
Date:
Title of Project:
Sponsor (funding agency):
Report all financial interest/relationships currently held, or held within the past 12 months (or during the
previous calendar year for annual disclosures), unless otherwise stated, indicating the amount of the financial
interest/relationship and the entity or organization. This form must be updated within 30 days of acquiring any
new or additional financial interests/relationships.
Ple
ase check and describe all applicable items that relate to the SFIs for you, your spouse, domestic partner, or
dependents:
1. Have you, your spouse, domestic partner, or dependents:
a) received remuneration from a publically traded entity whose value, when aggregated, is in excess o
f
$5,000.?
☐ Yes ☐ No
If yes, please describe each instance of salary or payment for services and dollar amounts:
b
) Do you have equity interests (e.g. stock, stock options, or other ownership interests) whose value, when
aggregated, is in excess of $5,000?
☐ Yes ☐ No
If yes, please describe each equity interest, including value of stock or ownership interest:
c) H
ave you received payment for Intellectual Property Rights (e.g. patents, copyrights, and royalties from
such rights) by an entity other than UWG?
☐ Yes ☐ No
If yes, please describe each instance of intellectual property rights, including amount paid:
d
) Sponsored or reimbursed travel (e.g. travel paid on your behalf)
☐ Yes ☐ No
If yes, please describe each instance of sponsored or reimbursed travel and dollar amount:
October 2013 (v.1)
2. Are you engaged in Government consultantships:
☐ Yes ☐ N
o
If y
es, please describe all such relationships:
3. Hav
e you engaged in an extramural program related to your research with either a government agency or
private firm within the past year?
☐ Yes ☐ N
o
If
yes, indicate the name of each such program and agency/firm:
4. Will
you, your spouse, domestic partner, or dependents receive any compensation contingent on the
outcome of the research?
☐ Yes ☐ No
If
yes, indicate the amount and explanation of source:
5. Ot
her: Please list any other item related to potential Financial Conflict of Interest which may be perceived as
significantly related to your research. These items may include: compensation for service on a Board of
Directors/Trustees; gifts, gratuities or anything on monetary value; loans; etc.
☐ Yes ☐ N
o
Ple
ase describe, indicate value, and explain how these interests reasonably appear to be related to your
institutional responsibilities:
By
signing below I attest that I:
a) have read the UWG Financial Conflict of Interest Policy, I have completed the required training, and I agree
to abide by the terms of the policy.
b) will update this disclosure on an annual basis for the term of my sponsored project, or as any new
reportable significant financial interests arise.
c) will comply with any management plan deemed necessary to manage/mitigate any real or perceived
financial conflict of interest.
d) understand the information supplied to the University and Office of Research & Sponsored Projects will be
reviewed in confidentially. I also understand that information regarding any financial conflicts of interest
may be disclosed to sponsors as required by law, regulation or contract.
Signature Date
Please return this form t
o: charlac@westga.edu
April 2016 (v.2)
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Fcoi Disclosure V2 2

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Completed 2 March 2020

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