Fillable Financial Disclosure Form for PIs/Senior Personnel Conducting Research (Tulsa Community College)

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Financial Disclosure Form for PIs/Senior Personnel Conducting Research (Tulsa Community College)

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The Financial Disclosure Form for PIs/Senior Personnel Conducting Research (Tulsa Community College) form is 6 pages long and contains:

  • 1 signature
  • 81 check-boxes
  • 113 other fields

Country of origin: US
File type: PDF

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(New Disclosures)
______________________________ ____________
Financial Disclosure Form for PIs/Senior Personnel
Conducting Research Funded by Federal Grants at Tulsa Community College
Investigator Name:
Project Name:
Source of Funds:
Status: ☐ Current ☐ Pending
Role in Project: ☐ PI ☐ Co-PI ☐ Senior/Key Personnel ☐ Consultant ☐ Unpaid Collaborator
☐ Other Investigator
In making the following certification and representations, please remember that all the following
must be included as significant financial interests:
• All financial interests pertaining to you personally;
• All pertaining to your spouse or registered domestic partner;
• All pertaining to a dependent child.
The following types of financial interests are excluded and should not be reported on this form as
significant financial interests:
• Salary, royalties, or other remuneration from Tulsa Community College;
• Income from investment vehicles such as mutual funds or retirement accounts, as long as
you do not directly control the investment decisions made in these vehicles;
• Income from seminars, lectures, or teaching engagements sponsored by, or service on
advisory committees or review panels for, or travel sponsored or reimbursed by any or all
of the following (U.S.-based entities only):
o Federal, State or local government agencies
o Institutions of higher education
o Academic teaching hospitals
o Medical centers
o Research institutes affiliated with institutions of higher education.
Check one of the following statements:
☐ I hereby certify that I have read the Financial Disclosure Policy in the Tulsa Community College
Grants Guide, which is effective for all Federal research proposals submitted through the College. I
certify to the best of my knowledge that neither I nor my spouse, partner, or dependents hold any
significant financial interests that would reasonably appear to be related to my research, teaching and
service responsibilities to Tulsa Community College.
☐ I have the following relationships, affiliations, activities, or interests which constitute significant
financial interests under the Tulsa Community College Conflict of Interest policy (see following pages):
Signature Date
click to sign
signature
click to edit
Publicly Traded Entities
Instructions: Copy as many times as needed for all publicly-traded entities. Do not include any
company for which subtotal of all financial interests < $5,000
Company Name and
Stock Market
Abbreviation
Interests Pertaining
to (check all that
apply):
Type of Interest
Value of Interest
☐
Self
☐ Spouse / Partner
☐ Equity
# Shares
Current
Market
Value
Total
Value
☐ Dependent Child
☐ Compensation
(total over last 12
Total Value
calendar months)
of
Relationship:
Subtotal (Total Equity Value + Compensation over last 12 months)
Non-Publicly Traded Entities (Equity Interests)
Instructions: List all non-publicly traded entities in which you, your spouse/partner and/or your
dependent child hold an equity interest, regardless of dollar value. Add rows if needed.
Estimated $ value and % ownership columns are optional, but the College reserves the right to
request this information during the Conflict of Interest determination process if these are left
blank.
Entity Name
Interests Pertaining
to (check all that
apply):
Entity Business
Type
Estimated $ Value
% Ownership
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
✔
✔
☐
Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
Non-Publicly Traded Entities (Compensation)
Instructions: List all non-publicly traded entities from which you, your spouse/partner and/or
dependent child have received compensation of $5,000 or more in the last 12 calendar months.
All columns must be completed in full. Add rows if necessary.
Entity Name
Interests
Pertaining to
(check all that
apply):
Position or
Relationship
Entity Business
Type
Total
Compensation in $
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐
Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐ Spouse / Partner
☐ Dependent Child
Compensation for Intellectual Property Rights
Instructions: This does not include any payment from Tulsa Community College for intellectual
property assigned to the College in conformance with the College’s Intellectual Property policy.
List all entities other than Tulsa Community College from which you, your spouse/partner and/or
your dependent child have received payment for intellectual property rights (e.g. royalties,
licensing fees, etc.) in the last 12 calendar months. Add rows if necessary.
Entity Name
Interests
Pertaining to
(check all that
apply):
Description of Intellectual Property
Total
Compensation in $
☐
Self
☐ Spouse / Partner
☐ Dependent Child
☐
Self
☐
Spouse / Partner
☐ Dependent Child
Sponsored or Reimbursed Travel
Instructions: List any instance of travel from the last 12 calendar months which was either
sponsored or reimbursed by an entity other than Tulsa Community College other than those
types of entities excluded on page 1, with a reimbursed or estimated cost exceeding $5,000.
Include any instance where reimbursement was made by Tulsa Community College from a fund
account sponsored by a non-excluded entity. Add rows if needed. Estimated cost column is
optional, but the College reserves the right to request this information from you or the sponsor
during the Conflict of Interest determination process if this space is left blank.
Traveler (check
Destination
Dates of
Purpose of
Sponsor Name
Estimated
all that apply) Travel Travel or
Reimbursement
Source
costs in $
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
☐
Self
☐ Spouse /
Partner
☐
Dependent
Child
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
☐
Self
☐ Spouse /
Partner
☐ Dependent
Child
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Financial Disclosure Form for PIsSenior Personnel Conducting Research (Tulsa Community College)

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Completed 3 October 2020

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