Florida Gulf Coast University
Financial Conflict of Interest Disclosure Report
Employee Name (printed)
Last Name First Name
You must fill out a separate form for each company in which you have a financial interest and update
each form annually or as changes occur.
This form is to be completed in connection with the Florida Gulf Coast University’s Policy on Financial Conflict
of Interest in Sponsored Research, 2.018 by all key personnel who are involved in the review, design, analysis,
conduct and/or reporting of research in which an entity of Florida Gulf Coast University is engaged. Answers
should be completed based on the 12 months prior to form completion.
Should you have questions about the form, you may contact: Research@fgcu.edu
Florida Gulf Coast University’s Office of Research & Graduate Studies will protect the confidentiality of private
investments and personal finances and will request information related only to financial relationships that might
influence the objectivity of research being conducted.
Your answer(s) to the questions do not imply that any financial interest you disclose is improper or impermissible.
However, failure to report a financial interest or furnishing false, misleading or incomplete information may
constitute professional misconduct and could be cause for disciplinary action.
I participate in Public Health Service (PHS) or NSF funded research ☐ Yes ☐ No
I am disclosing financial interest for (entity name): ______________________________________________
In relation to the Entity above, please note the following section on Financially Interested Company:
Significant Financial Interest: FGCU Policy 2.018 requires that you report any compensation that you receive
or Equity or Proprietary Interests that you have in an entity (i.e. the manufacturer of a product that is the
subject of your Research project(s), its agent, or a company that is a direct and primary competitor to the
manufacturer of the product) even if you purchased the Equity interest. The policy also requires that you
disclose whether you hold a fiduciary position with an entity even if the position is unpaid.
1) Research or services performed for this entity generates personal income paid directly to a member of
my immediate family or me. ☐ Yes ☐ No
If yes, please provide amount of income within the last year. $
2) A member of my immediate family or I receive(s) personal income for consulting or other services from
this entity. ☐ Yes ☐ No
If yes, please provide amount of income within the last year. $
3) A member of my immediate family or I receive(s) personal income for other services (e.g. advisory
services) for this entity. ☐ Yes ☐ No
If yes, please provide amount of income within the last year. $
4) A member of my immediate family or I receive(s) personal royalties from this entity. ☐ Yes ☐ No
If yes, please provide amount of income within the last year. $
5) A member of my immediate family or I has equity in this entity. ☐ Yes ☐ No
Financial Disclosure Form Dev. 4-2019 Page 1 of 2
