Knox College
Faculty and staff members employed by Knox College who are seeking or receiving
governmental or corporate support through the college for their research, scholarship,
educational or other professional endeavors are required to disclose to the College all
significant financial interests of the employee (including those of the employee’s spouse
and dependent children) –
(i) that may reasonably appear to be directly and significantly affected by the
research or other endeavors proposed for or receiving funding; or
(ii) in entities whose financial interests may reasonably appear to be directly
and significantly affected by such activities.
The term “significant financial interests” means 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 interests);
* and intellectual property rights (e.g., patents, copyright and royalties from
such rights).
I, , hereby
disclose the following significant financial interests that may reasonably be determined to
pose actual or potential conflicts of interest in the conduct of the project entitled:
which is being proposed for funding currently funded
My role on the project is
Name of Entity Nature of Significant Financial Interest*___________
I have read and will comply with all requirements of the Faculty Policy on Investigator
Financial Disclosure and Conflict of Interest, including providing updates of this
disclosure statement as new reportable financial interests are obtained and adhering to
any conditions or restrictions imposed by the college to manage, reduce or eliminate
actual or potential conflicts of interest.
___________________________________ __________________________________
Signature, Discloser Date signed Signature, Dean of the College Date signed
* If None, state “None.”