Fillable FederalD Merged File (California State University, Fresno)

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FederalD Merged File (California State University, Fresno)

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Office of Research and Sponsored Programs
Federal Disclosure Form
Please forward the completed form to the Office of Research and Sponsored Programs.
For questions, please contact our office at (559) 278-0840.
Office Telephone Number:
Department: Mail Stop:
DHHS/NIH
NSF
Other Federal Agency
E-mail address:
Home Address:
Title of Project:
Amount Applied for: $
Name of Principal Contact Person at Agency:
For Period:
Agency to which you are applying or from which the grant was received:
Office Telephone Number: E-mail address:
Name of Applicant and Spouse:
(Last, first , middle)
Name of the Funding Agency:
Please note: If you are applying to a non-governmental agency, please fill out the CA Form 700 U. You can download the form from the ORSP
web site at http://csufresno.edu/grants/pdfdocuments/conflictofinterest.pdf
First Disclosure Relating to this Proposal
Change, Renewal, or Extension of Grant or Contract
Change of Financial Interest Status
Final Disclosure Related to this Proposal
Significant (reportable) Financial Interests:
I have no reportable financial interests.
I have reportable financial interests declared on the attached
Please attach on numbered page(s) for each financial interest as follows:
1) Name and Address of Interest
2) Owners of Interest
3) Amount of your combined (applicant and spouse) investment in them
4) The nature and titles used your participation in them (salary, royalties, etc.)
5) Your intellectual property rights (patents, copyrights) being used by them
6) Any agreement for deferred remuneration, compensation, of financial gain of any kind
I have read all related campus, state and federal policies and regulations pertaining to Conflict of Interest.
I declare under penalty of perjury under the laws of the State of California that I have used all reasonable diligence in preparing
this Disclosure and that, to the best of my knowledge and belief , it is true and complete.
Signature:
_______ pages.
Date:
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Instructions and Definitions
Instructions:
Investigators are required to disclose Significant Financial Interest (SFI) whenever an
investigator applies for funding from National Science Foundation (NSF), Public Health
Service (PHS) agencies (e.g., NIH), or other agencies adopting federal requirements.
Investigators must disclose SFI annually during the life of a sponsored research project,
and within 30 days of discovering or acquiring a new SFI.
Definitions:
Investigator means the Principal Investigator, Co-Investigators, Project Directors, and
any other person at the institution who is responsible for the design, conduct, or
reporting of research activities funded or proposed for funding. For reporting of
Significant Financial Interest, “investigator” includes the investigator’s spouse and
dependent children.
Significant Financial Interest means anything of monetary value, including, but not
limited to:
▪ salary or other payments for services (e.g., consulting fees or honoraria)
▪ equity interests (e.g., stocks, stock options or other ownership interests)
▪ intellectual property rights (e.g., patents, copyrights and royalties from such rights)
The term does NOT include:
▪ salary, royalties, or other remuneration from the university
▪ income from seminars, lectures, or teaching engagements sponsored by public or
nonprofit entities
▪ income from service on advisory committees or review panels for public or nonprofit
entities;
▪ an equity interest that, when aggregated for the Investigator and the Investigator’s
spouse and dependent children meets both of the following tests:
(1) does not exceed $10,000 (or $5,000 for PHS projects) in value as determined
through reference to public prices or other reasonable measures of fair market
value, and
(2) does not represent more than a 5% ownership interest in any single entity.
▪salary, royalties or other payments that, when aggregated for the investigator and the
investigator’s spouse and dependent children over the next twelve months, are not
expected to exceed $10,000 (or $5,000 for PHS projects).
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FederalD Merged File (California State University, Fresno)

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Completed 20 July 2020

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