OfficeofResearchandTechnologyTransfer Rev.8/24/2012
WrittenRequestforInformationRelatedto
FinancialConflictsofInterestonPHSfundedResearch
UnderTitle42Part50SubpartF(PromotingObjectvityinResearch)and
Title45Part94(ResponsibleProspectiveContractors)
NameofRequestor:
StreetAddress:
City:State: Zip:
Emailaddress:
Phonenumber:
NameoftheProjectSenior/KeyPersonnelforwhichinformationrelatedtoansignificantfinancial
interest/financialconflictofinterestisbeingrequested:

ProjectTitle:
NameofSponsoringAgency(PHSFundedResearchOnly):
AwardNo.(ifknown):
Thesignificantfinancialinterestmustmeetallofthefollowingthreecriteriainordertobesubjectto
publicaccessibilityrequirementsofthefederalregulation:
A. TheSignificantFi nancialInterestwasdisclosedandisstillheldbythesenior/keypersonnelforthe
NIHfundedresearchprojectidentifiedbythe
Institutioninthegrantapplication,progressreport,or
anyotherrequiredreportsubmittedtotheNIH;
B. TheInstitutiondeterminesthattheSignificantFinancialInterestisrelatedtotheNIHfunded
research;and
C. TheInstitutiondeterminesthattheSignificantFinancialInterestisaFinancialConflictofInterest.
Pleaseemail
yourrequestto:FCOI@nova.edu