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FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 1 of 7
OSP Revised 2018-09
Office of Sponsored Programs
3301 College Avenue
Fort Lauderdale, Florida 33314
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE
(FID)
FORM
Reference: OSP Policy No. 16 – Policy on Financial Conflict of Interest in Sponsored Programs
Instructions:
Project Directors/Principal Investigators (PD/PI) are required to complete one FID form on behalf of the
Study Team. Individuals on the Study Team must disclose all their Significant Financial Interests and/or
those of their Family Members that reasonably appear to be related to the Investigator’s institutional
responsibilities to the Office of Research and Technology Transfer according to the process defined in OGC
Policy No. 16 - Policy on Financial Conflict of Interest in Sponsored Programs. Prior to submitting this
form, for proposals involving work with sub-awardees, subcontractors, and/or work at multiple sites, the
PD/PI should consult OSP Policy No.16 for the process of disclosure.
Each Study Team member has an ongoing responsibility to disclose Significant Financial
Interests/Obligations/Proprietary Interests related to the Investigator’s institutional responsibilities prior to
proposal submission and during the life of the award. The FID form may be used for this purpose. Once a
proposal is awarded, the PD/PI, on behalf of the Study Team, will update the FID annually (by each June
30th following initial disclosure) during the life of the award. Additionally, the FID must be updated by
the PD/PI on behalf of the Study Team, during the period of the award as new reportable financial interests
are obtained within thirty (30) days of discovering or acquiring a financial interest.
Definitions:
Family Members: The Investigator’s spouse, domestic partner, or dependent children.
Financial Interest: Anything of monetary value, whether or not the value is readily ascertainable, including but not
limited to salary, commissions, consulting fees, honoraria, equity interests, interests in real or personal property,
dividends, royalties, rent, capital gains, intellectual property rights, and forgiveness in debt.
Institutional Responsibilities: An Investigator’s professional responsibilities on behalf of the University which may
include activities such as research, research consultation, teaching, professional practice, Institutional committee
memberships, and service on University panels.
Investigator: The project director or principal Investigator (PD/PI) and any other person, regardless of title or position,
who is responsible for the design, conduct, reporting, or performing other substantive research activities for sponsored
programs as defined herein. Investigators may include academic appointees, staff or students, sub- awardees,
subcontractor, consultants, and to be appointed positions as well as any individual whose biographical sketch is
included in the proposal or whose name appears in the budget (including subcontract budgets). Spouses, domestic
partners, and dependent children are also included for the purposes of disclosure.
Obligations: Any formal and informal positions or relationships that would reasonably appear to be related to the
Investigator’s institutional responsibilities. Such positions might by paid or unpaid and include being an employee,
consultant, member of a speakers bureau, lecturer (for any purpose including educational or promotional lectures),
serving as an officer, board member (corporate, advisory, etc.), trustee, or director.
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 2 of 7
OSP Revised 2018-09
Proprietary Interests: All intellectual property rights that would reasonably appear to be related to the Investigator’s
institutional responsibilities.
Significant Financial Interest: Anything of monetary value, including, but not limited to, salary or other payments for
services (e.g., consulting fees, honoraria, paid authorship); equity interests (e.g., stocks, stock options or other
ownership interest); and intellectual property rights (e.g., patents, copyrights, and royalties from such rights), whether
or not the value is readily ascertainable, that reasonably appears to be related to the Investigator’s institutional
responsibilities.
• With regard to any publicly traded entity, if the value of any remuneration received from the entity in the
twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of
disclosure, when aggregated, exceeds $5,000.
• With regard to any non-publicly traded entity, if the value of any remuneration received from the entity in
the twelve months preceding the disclosure, when aggregated, exceeds $5,000, or when the Investigator (or
the Investigator’s spouse or dependent children) holds any equity interest (e.g., stock, stock option, or other
ownership interest);
• Intellectual property rights and interests (e.g., patents, copyrights), upon receipt of income related to such
rights and interests.
• The occurrence of any reimbursed or sponsored travel (i.e., that which is paid on behalf of the Investigator
and not reimbursed to the Investigator so that the exact monetary value may not be readily available), related
to their institutional responsibilities, no matter the dollar level.
Excluded from this disclosure are the following financial interests:
• Salary, royalties, or other remuneration from the University if the Investigator is employed by the University;
• Income from investment vehicles, such as mutual funds and retirement accounts, as long as the Investigator
does not directly control the investment decisions made in these vehicles even if higher than the $5,000
significant financial interest threshold;
• Income from seminars, lectures, or teaching assignments sponsored by a federal, state, or local government
agency of the U.S., an institution of higher education within the U.S. as defined at 20 U.S.C. 1001(a), an
academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of
higher education within the U.S.;
• Income from service on advisory committees or review panels for a federal, state, or local government agency
of the U.S., an institution of higher education within the U.S. as defined at 20 U.S.C. 1001(a), an academic
teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher
education within the U.S.;
• Travel that is reimbursed or sponsored by a federal, state, or local government agency of the U.S., an
institution of higher education within the U.S. as defined at 20 U.S.C. 1001(a), an academic teaching hospital,
a medical center, or a research institute that is affiliated with an institution of higher education within the
U.S.;
• Intellectual property rights assigned to the Institution and agreements to share in royalties related to such
rights;
Sponsored Program: For purposes of the policy on Financial Conflict of Interest in Sponsored Programs, a sponsored
program is a project or activity undertaken within the University pursuant to funding from an external source to support
research, teaching/training and community service.
Sponsored Travel: Travel which is paid on behalf of the Investigator, but which is not reimbursed to the Investigator
so that the exact monetary value may not be readily available.
Study Team: Any person, including the project director or principal Investigator, who is responsible for the design,
conduct or reporting of the research described in the proposal including sub-awardee(s), sub-contractor(s), consultants
and “to be appointed” positions as well as any individual whose biographical sketch is included in the proposal or
whose name appears in the budget (including subcontract budgets). A Study Team member’s spouses, domestic
partners, and dependent children are also included for purposes of disclosure and conflict of interest review.
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 3 of 7
OSP Revised 2018-09
Project Description:
Project Director/Principal Investigator:
Full Academic Title:
College/Department/Division:
Is this a New FID or an Update to an existing FID:
New FID
Research Project Title:
Anticipated Sponsor(s) of Funding Sources:
Senior/Key Personnel:
Please list all contractor(s)/subcontractor(s) named in the proposal, including any non-University study
site(s):
Are there any trainees (students, postdoctoral, fellows, etc.) who may participate in the proposed project?
Yes No
To the best of your knowledge, does Nova Southeastern University or any institutional official have a
financial interest (e.g. equity, royalty) related to the proposed activity?
Yes No
Declaration of Financial Interests/Obligation/Proprietary Interests
The University requires declaration and disclosure of significant financial interests, obligations and
proprietary interests that currently exist or have existed during the previous 12 months that reasonably
appear to be related to the Investigator’s institutional responsibilities. As PD/PI, you are completing this
FID on behalf of the Study Team which includes any and all sub-awardees, subcontractor(s), and
consultants as well as spouses, domestic partners, and dependent children. In completing this form, please
be sure to reference Policy No. 16 – Policy on Financial Conflict of Interests in Sponsored Programs and
the definitions set forth above.
1. D
o you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest that reasonably appears to be related to an Investigator’s institutional
r
esponsibilities? Yes No Explain if Yes:
2. Do you or any member of the Study Team serve as a consultant, member of an advisory boar
d
(
including scientific or trial design boards), member of a speaker’s bureau, lecturer, or hold a positio
n
of
management, such as board member, director, officer, partner or trustee with a sponsor, a vendor or
(sub)contractor related to the proposed activity or an Investigator’s institutional responsibilities?
Yes No Explain if Yes:
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 4 of 7
OSP Revised 2018-09
3. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a publicly traded entity that reasonably appears to be related to the proposed
activities or an Investigator’s institutional responsibilities? Yes No Explain if Yes:
4. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a non-publicly traded entity that reasonably appears to be related to an
Investigator’s institutional responsibilities? Yes No Explain if Yes:
5. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a Sponsor, a vendor or (sub)contractor related to the proposed activity or to an
Investigator’s institutional responsibilities? Yes No Explain if Yes:
6. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a for-profit entity that will manufacture or commercialize any drug vaccine,
device, project, procedure, or process that is associated with or that will predictably result from the
proposed activity? Yes No Explain if Yes:
7. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a for-profit entity that can reasonably be expected to benefit directly and
significantly from the design, conduct, or reporting of the proposed activity?
Yes No Explain if Yes:
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 5 of 7
OSP Revised 2018-09
8. Do you or any member of the Study Team have any significant financial interest, obligation, or
proprietary interest in a not-for-profit entity that can reasonably be expected to benefit directly and
significantly from the design, conduct, or reporting of the proposed activity?
Yes No Explain if Yes:
9. Have you or any member of the Study Team assigned rights to a Sponsor, vendor or (sub) contractor
related to the proposed activity for a disclosed intellectual property, pending patent application or an
issued patent to an invention(s), or copyright for software?
Yes No Explain if Yes:
10. Do you or any member of the Study Team have a specific significant financial interest in any entity
that can reasonably be expected to compete with the product or procedure that will predictably result
from the work described in the application? Yes No Explain if Yes
11. Is it reasonable to anticipate that you or any member of the Study Team have significant financial
interests that could directly and significantly be affected by the design, conduct, or reporting of the
proposed activity? Yes No Explain if Yes:
12. Have you or any member of the Study Team received any reimbursed or sponsored travel related to an
Investigator’s institutional responsibilities? Yes No Explain if Yes:
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 6 of 7
OSP Revised 2018-09
13. Do you or any member of the Study Team receive payment from a third party that is or might appear
to be affiliated with a sponsor, vendor or subcontractor involved in this proposed activity?
Yes No Explain if Yes:
14. Do you or any member of the Study Team receive payment from a third party that reasonably appears
to be related to an Investigator’s institutional responsibilities?
Yes No Explain if Yes:
15. Do you or any member of the Study Team have any ownership interests in an entity that is an applicant
under Phase II or Phase III of the Small Business Innovation Research (SBIR) or Small Business
Technology Transfer (STTR) Programs? Yes No Explain if Yes:
16. Do you or any member of the Study Team have any other financial interest, obligation, or proprietary
interest for which you are unsure whether a potential conflict of interest exists?
Yes No Explain if Yes:
17. If “Yes” to any of the questions above, provide the name(s) of the Study Team member(s) with the
financial interest/obligation/proprietary interest:
Each Study Team member named in #17 above is required to complete a separate Individual Interest
Disclosure (IID) form. This form can be found at http://www.nova.edu/fcoi
. These forms are confidential
and must be submitted directly by the responding Study Team member to the Office of Sponsored Programs
to be forwarded to the Office of Research & Technology Transfer for review.
FINANCIAL INTERESTS/OBLIGATIONS/PROPRIETARY INTERESTS DISCLOSURE (FID) FORM
Page 7 of 7
OSP Revised 2018-09
PROJECT DIRECTOR/PRINCIPAL INVESTIGATOR CERTIFICATION
All PDs/PIs are required to certify the FID. Add additional signature pages if required. For proposals with
multiple PDs/PIs, only one FID form is required but ALL PDs/PIs must sign the FID form. For proposals
with co-investigators, only the PD/PI signs the FID form.
I certify that all answers to this declaration are accurate and truthful to the best of my knowledge. I agree
to file an updated FID and IIF Form if and when the answers above change for any reason.
Print Name
Signature
Date
Print Name
Signature
Date
Print Name
Signature
Date
FIRST-LEVEL REVIEW (DEAN/DIRECTOR)
I have reviewed this disclosure and:
find no conflict of interest (no “Yes” responses on the FID form and no further review is required).
find a potential conflict of interest exists and second-level review is required.
Dean/Director
Date
SECOND-LEVEL REVIEW (VP-RESEARCH & TECHNOLOGY TRANSFER)
I have reviewed this disclosure and:
no conflict of interest exists.
a potential conflict of interest exists and completion/review of Individual Investigator(s) Disclosure(s)
(IIDs) is required.
Gary Margules, Sc.D.
VP
-Research & Technology Transfer
margules@nova.edu
Date
NOTE: Once the FID form is reviewed and signed by the dean/director indicating their finding, the form will be forwarded
by the PI/PD (with all other required pre-award forms) to the Office of Sponsored Programs. The Office of Sponsored
Programs will forward the FID to the Office of Research & Technology Transfer for Second-Level Review, as applicable,
and signature.
In those instances where a FID indicates a Study Team member must complete an IID, the IID should be submitted by the
Study Team member to the Office of Sponsored Programs for forwarding to the Vice President for Research and Technology
Transfer for second-level review. Dean or director review of the IID is not required. All IIDs must be submitted prior to
application submission for PHS-funded research.
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Completed 23 July 2020

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