Fill - Free fillable Individual-interest-disclosure-form - IID (RTT Version)7_24

INDIVIDUAL INTEREST DISCLOSURE (IID) FORM

Reference: OSP Policy No. 16 – Policy on Financial Conflict of Interest in Sponsored Programs

Instructions:

Each Study Team member identified on the FID form for this proposal is required to disclose significant

financial interests, significant obligations and proprietary interests related to the Investigator’s

institutional responsibilities or to the project that currently exist and that existed during the previous 12

months.

Each Study Team member has an ongoing responsibility to disclose potential financial interests related to

the Investigator’s institutional responsibilities prior to proposal submission and annually (by each June 30

following initial disclosure) during the life of the award. If the information included in this IID changes

during the pendency of the award, the Study Team member is responsible for submitting an updated IID

within thirty (30) days.

The IID form shall be submitted directly to the Office of Sponsored Programs for forwarding to the

Office of Research & Technology Transfer.

Definitions:

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 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,

subcontractors, 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.

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 or honoraria); 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.

Office of Sponsored Programs

3301 College Avenue

Fort Lauderdale, Florida 33314

INDIVIDUAL INTERESTS DISCLOSURE (IID) FORM

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 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.

A Significant Financial Interest does not include the following:

 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 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 and interests (e.g., patents, copyrights), when the rights are assigned to

the institution and related agreements.

Disclosures might include (but are not limited to) significant financial interest, significant obligation, or

proprietary interest in:

 The entity to which the proposal will be submitted;

 Any entity that owns or has applied for the patent manufacturing or marketing rights to product or

procedure involved in, or will predictably result from, the work described in the proposal;

 Any entity that will be a sub-recipient from the University funding resulting from the proposal;

 Any entity that would reasonably be considered as a competing entity with the sponsor of the proposed

activity.

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 or 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.

Name of Lead Principal Investigator:

Research Project Title:

Anticipated Sponsor(s) or Funding Sources:_________________________________________________

The items below must be answered separately for each source in which you have a Significant Financial

Interest, Obligation, or Proprietary Interest that would reasonably appear to relate to your Institutional

Responsibilities or reasonably appear to affect or be affected by the research project. This includes

companies that can reasonably be expected to compete with the product or procedure that will predictably

result from the work described in the application.

Please make additional copies of this section or selected pages as necessary.

Source of Interest:

INDIVIDUAL INTERESTS DISCLOSURE (IID) FORM

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General Information:

Name of Study Team member whose information is contained herein:

Full Academic Title:

College/Department/Division:

Briefly describe your Institutional Responsibilities as you understand them to be:

Is this a New IID or an Update to an existing IID: New IID

Update to existing IID

1. Briefly describe the nature of your interest (including i

nterests of your spouse, domestic partner,

and/or dependent children) with this entity.

2. Briefly describe the nature of your interest with the entit

y as it relates to your Institutional

Responsibilities

3. Briefly describe the nature of the entity’s involvement with the proje

ct for which this application is

being submitted.

INDIVIDUAL INTERESTS DISCLOSURE (IID) FORM

Page 4 of 5

4. Please indicate the type(s) of interest(s) with this entity that have existed during the previous 12

months, and that currently exist. Please provide details including when interest held and specific

amounts if financial. Also, please be sure to refer to the definitions when completing this section.

Significant Fi

nancial Interest:

Obligation:

Proprietary Interest:

5. Please indicate and describe any occurrence of reimbursed or sponsored travel related to y

our

Institutional Responsibilities. Travel that is reimbursed or sponsored by a federal, state, or local

government agency, an institution of higher education 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 doe

s not need to be reported.

Purpose of Trip

The identity of the sponso

r/organizer

Destina

tion

Duratio

y Value

6. Is there any additional information that may be relevant to the institutional review

of this application

for actual, apparent, or potential conflict of interest? If yes, please attach information.

Yes No

7. Are you named in an existing conflict of interest management plan that is relevant to the work and/or

one of the entities describe

d herein? If yes, please attach information.

Yes No

Investigator Certification

I affirm

my understanding that many conflicts of interest can be managed, reduced, or eliminated after an

appropriate evaluation. Further, I understand that the proposed research may not proceed in the absence of

such an evaluation. The evaluation will be conducted by the VP-Research and Technology Transfer for

the purpose of determining what conditions or restrictions, if any, should be imposed by the institution to

manage, reduce, or eliminate such conflicts of interest. I will assist the Office of Research and

Technology Transfer and other appropriate University authorities in obtaining the information they need

promptly to complete this evaluation. If a management plan is deemed necessary, I will assist in its

development and cooperate in its implementation. I will submit an amended Individual Interest

Disclosure form if any circumstances relevant to this disclosure change during the life of the award.

INDIVIDUAL INTERESTS DISCLOSURE (IID) FORM

Page 5 of 5

I hereby certify that the information I provided is true, accurate, and complete regarding this

disclosure as

related to this research project or sponsored program.

Print Name Signature Date

Please forward the completed and signed form directly to the Office of Sponsored Programs for

forwarding to the Office of Research & Technology Transfer.

INDIVIDUAL INTEREST D

ISCLOSURE (IID) FORM REVIEW

I have reviewed this Individual Interest Disclosur

e Form (IID) for the purpose of determining

what conditions or restrictions, if any, should be imposed b

y the institution to manage, reduce, or

eliminate conflicts of interest in sponsored program

s, and have determined that:

No significant financial interests/obligat

ions/proprietary interests relate to the proposed

program

An actual or potential conf

lict of interest exists.

If an actual or potential conflict of interest exists

, the Office of Research and Technology Transfer

will notify the Investigator and work with him/

her in the development and implementation of a

management plan.

______________________________________

Gary Margules, Sc.D.

_____________

Date

VP-Research & Technology Transfer

Margules@nova.edu

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