Fillable LU Form Fcoi-disclosure

Fill Online, Printable, Fillable, Blank LU Form Fcoi-disclosure Form

Use Fill to complete blank online LIBERTY UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

LU Form Fcoi-disclosure

On average this form takes 9 minutes to complete

The LU Form Fcoi-disclosure form is 3 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Liberty University

BROWSE LIBERTY UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Liberty University
Financial Conflict of Interest Disclosure Form
Do I have a Financial Conflict of Interest under LU’s Policy: Conflict of Interests Disclosure for Sponsored Programs?
A Financial Conflict of Interest Disclosure Form (DF) is required for all persons applying for or receiving funding from
federal sponsors for research projects or any funding received by Public Health Service Agencies (PHS). DF’s will be
evaluated regarding significant financial interests in non-university (non-LU) entities. These regulations apply to
current interests and interests in the 12 months preceding the submission of the DF, rather than interests that are
anticipated in the future.
If you need assistance filling out the Financial Conflict of Interest Disclosure Form, contact the Office of Sponsored
Programs at (540) 582-4667 or http://www.liberty.edu/offices/sponsoredprograms/
Basic Information
Name:
Email:
Department:
Sponsor: Public Health Service (PHS) Other:
I am an external investigator
(non-LU employee)
: My organization
LU's PI
Type of Disclosure
New Amended Annual Reporting
Disclosure: For the purpose of this disclosure, Institutional Responsibilities mean an investigator’s professional responsibilities on
behalf of the university which may include activities such as research, research consultation, teaching, professional practices,
institutional committee memberships, and service on panels.
Entity: Any domestic or foreign, public or private, organization (excluding a Federal agency) from which an Investigator (and
spouse and dependent children) receives remuneration or in which any person has an ownership or equity interest.
Publicly Traded Entity: A company which has issued securities (stock/shares, bonds/loans, etc.) through an offering, which are
now traded on the open market (opposite of a private company).
1. Publicly Traded Entity (Income & Equity Interests)
Have you or your spouse, and/or dependent children received income or payment for services for the past 12 months or
own equity (stock) interest in any publicly traded entity related to your institutional responsibilities exceeding $5,000 when
aggregated? This does not include interests in mutual funds and retirement funds in which you do not directly control
investment decisions.
YES NO
If yes, please provide the following:
Name of entity:
Nature of the significant financial interest (e.g., equity, consulting fees, travel reimbursement, honoraria):
Value of the significant financial interest or statement why a value cannot be readily determined:
2. Non-Publicly Traded Entity (Income)
Have you or your spouse, and/or dependent children received income or other payment for services, in the past 12 months,
exceeding $5,000, when aggregated, from any non-publicly traded entity? This does not include income from seminars,
lectures, or teaching engagements sponsored by a U.S. federal, state, or local government agency, a U.S. institution of
higher education or an affiliated research institute, an academic teaching hospital, or a medical center.
YES NO
If yes, please provide the following:
Name of entity:
Nature of the significant financial interest (e.g., equity, consulting fees, travel reimbursement, honoraria):
Value of the significant financial interest or statement why a value cannot be readily determined:
(Equity Interests) Do you or your spouse, and/or dependent children currently own, or have acquired in the past 12
m
onths, any equity interest in any non-publicly traded entity related to your institutional responsibilities? This can
include any stock, stock option or other ownership interest.
YES NO
If yes, please provide the following:
Name of entity:
Nature of the significant financial interest (e.g., equity, consulting fees, travel reimbursement, honoraria):
Value of the significant financial interest or statement why a value cannot be readily determined:
3. Intellectual Property Rights and Interests
Have you or your spouse, and/or dependent children received any payments, in the past 12 months, for any intellectual
property rights and interests (e.g. patents, copyrights, assigned or licensed to a party other than LU) exceeding $5,000
related to your institutional responsibilities?
YES NO
If yes, please provide the following:
Name of entity:
Nature of the significant financial interest (e.g., equity, consulting fees, travel reimbursement, honoraria):
Value of the significant financial interest or statement why a value cannot be readily determined:
4. Travel Reimbursement/Scholarship
Have you received travel reimbursement or been sponsored for travel (i.e. travel expenses paid on behalf of Investigator
and not reimbursed to Investigator) in excess of $5,000 per entity in the 12 months prior to disclosure, by any entity related
to your institutional responsibilities? This does not include travel sponsored or reimbursed by a U.S. federal, state, or local
government agency, a U.S. institution of higher education or an affiliated research institute, an academic teaching hospital,
or a medical center.
YES NO
Please provide a brief description of the following:
Purpose of trip:
Sponsor/organizer:
Destination:
Duration:
*The disclosure requirement does not apply to travel that is reimbursed or sponsored by the following:
• a federal, state, or local government agency,
• an Institution of higher education as defined by 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
Acknowledgement & Certification
I have read LU’s Policy on Conflict of Interests Disclosure for Sponsored Programs and I certify under penalty of perjury that
this is a complete disclosure of all my significant financial interests related to my institutional responsibilities. I have used all
responsible diligence in preparing this Financial Interest Disclosure and to the best of my knowledge, it is true and complete. I
also acknowledge that by signing my name below that it is my responsibility to disclose, within 30 days, any new significant
financial interests obtained during the term of the above proposed project to the Office of Sponsored Programs.
Name of Investigator (Printed):
Signature of Investigator: Date:
Received by Office of Sponsored
Programs:
Date:
COI Committee Review (if applicable): Date:
* If you require additional space to list your Significant Financial Interests, please attach additional pages as needed.
If you have any questions related to this form please contact:
Office of Sponsored Programs
Green Hall, 2725
(434) 582-4667
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

LU Form Fcoi-disclosure

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 12 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document