Nova Southeastern University
Office of Sponsored Programs
3301 College Avenue
Fort Lauderdale, Florida 33314
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.
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.
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
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:
1. Briefly describe the nature of your interest (including interests of your spouse, domestic partner,
and/or dependent children) with this entity.
2. Briefly describe the nature of your interest with the entity as it relates to your Institutional
Responsibilities
3. Briefly describe the nature of the entity’s involvement with the project for which this application is
being submitted.
INDIVIDUAL INTERESTS DISCLOSURE (IID) FORM
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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 Financial Interest:
Obligation:
Proprietary Interest:
5. Please indicate and describe any occurrence of reimbursed or sponsored travel related to your
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 does not need to be reported.
Purpose of Trip
The identity of the sponsor/organizer
Destination
Duration
Monetary 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 described 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
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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 DISCLOSURE (IID) FORM REVIEW
I have reviewed this Individual Interest Disclosure Form (IID) for the purpose of determining what
conditions or restrictions, if any, should be imposed by the institution to manage, reduce, or
eliminate conflicts of interest in sponsored programs, and have determined that:
___________No significant financial interests/obligations/proprietary interests relate to the
proposed program
___________An actual or potential conflict 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