Fill - Free fillable Fcoi-information-request-form FCOI Information Request Form

OfficeofResearchandTechnologyTransfer Rev.8/24/2012

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WrittenRequestforInformationRelatedto

FinancialConflictsofInterestonPHS‐fundedResearch

UnderTitle42Part50SubpartF(PromotingObjectvityinResearch)and

Title45Part94(ResponsibleProspectiveContractors)



NameofRequestor:

StreetAddress:

City:State:  Zip: 

Emailaddress:

Phonenumber:

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NameoftheProjectSenior/KeyPersonnelforwhichinformationrelatedtoansignificantfinancial

interest/financialconflictofinterestisbeingrequested:





ProjectTitle:



NameofSponsoringAgency(PHS‐FundedResearchOnly):

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AwardNo.(ifknown):

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Thesignificantfinancialinterestmustmeetallofthefollowingthreecriteriainordertobesubjectto

publicaccessibilityrequirementsofthefederalregulation:

A. TheSignificantFi nancialInterestwasdisclosedandisstillheldbythesenior/keypersonnelforthe

NIH‐fundedresearchprojectidentifiedbythe

Institutioninthegrantapplication,progressreport,or

anyotherrequiredreportsubmittedtotheNIH;

B. TheInstitutiondeterminesthattheSignificantFinancialInterestisrelatedtotheNIH‐funded

research;and

C. TheInstitutiondeterminesthattheSignificantFinancialInterestisaFinancialConflictofInterest.



Pleaseemail

yourrequestto:FCOI@nova.edu

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