Fillable Letterofintentslumain - LOI Form - SLU as PRIME(1)

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Letterofintentslumain - LOI Form - SLU as PRIME(1)

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Letter of Intent to Establish a Consortium Agreement
Saint Louis University as Primary Applicant
Saint Louis University PI:
Subcontract Organization:
SLU PI Department:
Subcontract PI:
Sponsor Name:
Proposal Title:
Proposed Project Period: to Proposed Project Amount: $
Attached Subcontract Proposal Documents
Scope of Work (required)
Budget and Budget Justification (required)
Biosketches and Other Support for all Key Personnel – in agency required format (if applicable)
Non-SLU Financial Conflict of Interest Disclosure Form (if applicable – see below)
Federally negotiated F&A Costs Rate Agreement (required for Federal sponsors)
If not attached, please provide website for agreement:
Project/Performance Site Location
Organization Name:
County:
Street 1:
Country:
Street 2:
Province:
City:
Congressional District:
State:
DUNS #
Zip/Postal Code:
EIN #
Year 1 Subcontract Budget
Total Subcontract Budget
Direct Costs
Direct Costs
F&A Costs
F&A Costs
Total Costs
Total Costs
Are Animals Applicable to this Proposed Project?
Yes No
Are Human Subjects Applicable to this Proposed Project?
Yes No
The appropriate programmatic and administrative personnel of each institution involved in this grant application are aware of
the pertinent Federal regulations and policies and are prepared to establish written inter-organizational agreements that will
ensure compliance with all such policies.
Please select one:
Subcontractor has a Financial Conflict of Interest (COI) policy that complies with the Department of Health and Human
Services, “Objectivity in Research,” 42 CFR Part 50 and “Responsible Prospective Contractors,” 45 CFR Part 94 requirements.
This form further stipulates that all individuals participating on this project are compliant with such policy.
or
Subcontractor does not have a Financial Conflicts of Interest (COI) policy that complies with the Department of Health and
Human Services, “Objectivity in Research,” 42 CFR Part 50 and “Responsible Prospective Contractors,” 45 CFR Part 94
requirements and will comply with Saint Louis University’s Financial Conflict of Interest in Research Policy. Subcontractor
further understands that all individuals participating on this project must complete a Non-SLU Financial Disclosure Form
(attached) prior to the submission of any external application. A training course for Conflict of Interest will also be required
from all participants if the proposal is funded.
_______________________________________________ ____________
Signature of Authorized Official Date
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signature
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INTRODUCTION: Saint Louis University’s Conflict of Interest in Research Policy requires disclosure of financial
interests for faculty, staff, students, subcontractors, consultants, collaborators and all others engaged in externally sponsored
programs. In academic research institutions, conflicts of interest are not uncommon, and the existence of a financial interest
does not in any way indicate wrongdoing. However, a real or perceived financial conflict of interest may compromise or
appear to compromise professional judgment or integrity on the part of the conflicted individual. Therefore, financial
conflicts of interest must be managed, reduced, or eliminated. Saint Louis University’s Financial Conflict of Interest in
Research Policy is designed to comply with federal regulations and at the same time safeguard the integrity of the institution,
its researchers and collaborators.
SLU’s policy requires that all individuals participating in externally sponsored programs complete Conflict of
Interest in Research Disclosure Forms annually and within 30 days of the time at which a financial conflict arises or the
status of a previously filed disclosure changes. Full disclosure is key to handling potential conflicts so that SLU’s Conflict of
Interest in Research Committee can work with individuals to develop, implement, and monitor an appropriate management
plan.
A Significant Financial Interest (SFI) exists when the following conditions are present for the individual or when
aggregated with the interests of his/her spouse and dependent children:
x Any combined income, compensation or stock in excess of $5,000 from a publicly-traded or non-publicly
traded entity;
x Any amount of equity (stock, stock options, or other ownership interest) in a non-publicly traded entity (such
as a start-up company)
x Any reimbursed or sponsored travel to the Investigator paid by an entity, including non-profit organizations,
but excluding travel sponsored by or reimbursed by a government agency, a U.S. institution of higher
education or a research institute affiliated with such, a medical center, or an academic teaching hospital.
x NOTE: A Significant Financial Interest does not include salary, royalties or other remuneration from Saint
Louis University, your organization, or payments from governmental organizations for seminars, lectures,
service on advisory committees or service on review panels.
INSTRUCTIONS: All individuals engaged in externally funded research are required to complete a Conflict of Interest
Disclosure Form PRIOR TO SUBMITTING A GRANT APPLICATION if a current annual disclosure has not been
completed. Please read and follow instructions for each section of this Disclosure Form. When you have completed the form,
submit to the Division of Research Administration, c/o Johnny Kidd, Manager of Responsible Conduct of Research,
Fusz Hall, Room 262, Saint Louis, MO 63108 or by e-mail to COI@slu.edu.
Any questions regarding the policy or completion of this disclosure form should be directed to Johnny Kidd, Manager of
Responsible Conduct of Research at 314-977-7047, or jkidd2@slu.edu.
Financial Conflict of Interest in Research Disclosure Form
for Non-SLU
p
ersonnel
2012 Conflict of Interest in Research Disclosure Form
TYPE OF DISCLOSURE: (Please check appropriate box.)
Annual Disclosure Amended Disclosure
SECTION I - CONTACT INFORMATION: Please fill out completely. Type.
Name:
Address:
Phone:
E-mail:
SECTION II - PROJECT INFORMATION: Please fill out completely. Type.
Title of Project:
SLU Principal Investigator:
Project Number (if known):
Your role in the project:
SECTION III – Disclosure of Financial Interests: Please fill out completely. Type.
1. Have you, your spouse or dependent children received $5,000 or more directly from a
potential research sponsor?
In this section, please indicate ‘yes’ to the following: (1) if intellectual property rights are worth
more than $5,000; and (2) if personal compensation such as salary, royalties, consulting fees,
honoraria or other payments from a potential research sponsor exceed $5,000 per year. Remember
that within the Conflict of Interest Disclosure Form, an individual must consider their spouse and
dependent children to be one and the same with the individual. Also note that this does not include
salary, royalties or other remuneration from your organization, or payments from government
agencies for seminars, lectures, service on advisory committees or service on review panels.
Yes No
2. Are you, your spouse or dependent children a shareholder, or otherwise hold >$5,000
of equity interest from a publicly traded company that is considered to be a potential
research sponsor?
Yes
No
3. Are you, your spouse or dependent children a shareholder, or otherwise hold ANY
equity interest from a non-publicly traded company that is considered to be a potential
research sponsor?
Yes
No
4. Do you, your spouse or dependent children, currently hold a position with a non-SLU
organization/company (other than your own organization) that may come in conflict
with your responsibilities as a collaborator with SLU?
Yes
No
5. Have you previously had a Significant Financial Interest that required a management
plan from Saint Louis University’s Conflict of Interest in Research Committee?
Yes
No
If all your responses are “NO” in Section III, you may check this EZ Disclosure box. EZ Disclosure
If you answered “NO” to each question in Section III, skip to the end of this form. Read the Disclosure Certification, sign and return to
Saint Louis University as indicated on the introduction page. If you answered “YES” to any question, you must complete all remaining
sections of this form as appropriate.
Financial Conflict of Interest in Research Disclosure Form
for Non-SLU
p
ersonnel
2012 Conflict of Interest in Research Disclosure Form
SECTION IV – Details of Significant Financial Interest: Please fill out completely. Type.
Name of
Entity
Type of Financial or Personal Interest
(check all that apply)
Value Per Year
Previous Calendar Year Current Calendar Year
(anticipated, if known)
Entity Name:
Consulting
Honoraria
Salary
Speaking Fees
Gifts
CME Sponsorship
Total Amount:
$
Total Amount:
$
Licensing Agreement or Royalty Income
Equity interests (*see below)
Serving on Scientific Advisory Board or Board of Directors
Other:
Entity Name:
Consulting
Honoraria
Salary
Speaking Fees
Gifts
CME Sponsorship
Total Amount:
$
Total Amount:
$
Licensing Agreement or Royalty Income
Equity interests (*see below)
Serving on Scientific Advisory Board or Board of Directors
Other:
Entity Name:
Consulting
Honoraria
Salary
Speaking Fees
Gifts
CME Sponsorship
Total Amount:
$
Total Amount:
$
Licensing Agreement or Royalty Income
Equity interests (*see below)
Serving on Scientific Advisory Board or Board of Directors
Other:
1. Name of Company: 2. Name of Company:
No. of Shares of Stock: No. of Shares of Stock:
Value of Stock Options: Value of Stock Options:
% Ownership of Company: % Ownership of Company:
SECTION V – Intellectual Property: Please fill out completely. Type.
If you have a significant financial interest in an organization that produces a technology or product that is a focus of your
research, list this technology or product and indicate which project utilizes it.
A. In the space below, please provide information regarding the entities with which you had a Significant Financial Interest
(SFI) in the past calendar year or for which you anticipate a SFI in the current calendar year. Entities include public
companies, corporations, speakers’ bureaus, media companies, and educational forums. DO NOT INCLUDE salary,
royalties or other remuneration from your organization, or payments from government agencies for seminars,
lectures
,
service on advisor
y
committees or service on review
p
anels.
B. Equity Interests: If you indicated in section III (above), that you have an equity interest, please complete the following
information regarding equity interests for yourself, your spouse, and dependent children. (Use additional sheets if necessary.)
2012 Conflict of Interest in Research Disclosure Form
DISCLOSURE CERTIFICATION
By submitting this Conflict of Interest in Research Disclosure form, I certify that the information contained herein is complete
and accurate to the best of my knowledge; and I acknowledge my continuing obligation to inform Saint Louis University’s
Division of Research Administration of any change in my outside activities at time of discovery by completing and submitting
an amended disclosure. Further, I accept the responsibility as a collaborator with Saint Louis University to inform others in my
organization also involved in research at Saint Louis University that they are also required to submit a Conflict of Interest in
Research Disclosure form.
Signature of Individual Date
Printed Name of Individual
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signature
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2012 Conflict of Interest in Research Disclosure Form
Name:
Grant Title/Number:
SLU Principal Investigator:
Start
Date
End
Date
Destination
Name of
Reimbursing
Entity
Purpose
Intended
Recipient*
Spouse’s
travel paid?
(Y/N)**
Children’s
travel paid?
(Y/N)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Travel Disclosure for Non-SLU Personnel
Instructions: Provide your name, Grant Title/Number, SLU PI, and complete the table below. E-mail a copy to Saint Louis University
Conflict of Interest at COI@slu.edu or fax to 314-977-2026.
Saint Louis University’s Financial Conflict of Interest in Research Policy requires any covered individual to report the details
of any travel reimbursed or paid for on behalf of an individual by an outside entity within 30 days of each occurrence.
Examples of outside entities include professional societies, foreign institutions of higher education, and for-profit and non-
profit entities.
Required disclosure: You are required to disclose travel paid on behalf of yourself, your spouse, and/or your dependent
children, regardless of their affiliation with Saint Louis University.
Exempted travel: You are not required to report travel paid by SLU or other U.S. institutions of higher education; U.S.
federal, state, or local government agencies; or, academic teaching hospitals, medical centers, or research institutes affiliated
with an institution of higher education.
*Intended recipient is the person for whom the travel was reimbursed (i.e., you, your spouse, or your dependent children).
**If the intended recipient is your spouse – “Spouse’s travel paid” is meant to encompass whether your travel was reimbursed.
Financial Conflict of Interest in Research Disclosure Form
for Non-SLU
p
ersonnel
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Letterofintentslumain - LOI Form - SLU as PRIME(1)

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Completed 22 March 2020

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