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MARINE BIOLOGICAL LABORATORY CONFLICT OF INTEREST DISCLOSURE Privileged (Marine Biological Laboratory)

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COI_8.19.2019AC.docx | PAGE 1
MARINE BIOLOGICAL LABORATORY
CONFLICT OF INTEREST DISCLOSURE
Privileged Statement of Organizational Affiliations and Significant Financial Interests
(This disclosure must be submitted as indicated in Table 1 and at any time when the disclosure needs to be
updated)
For persons supported by Federally-sponsored activities, the form will be kept on file until three years
after the Federal award expires. If deemed necessary, the Director of Research Administration and
Sponsored Programs or the Director of Human Resources of the MBL may request additional information.
NAME: TITLE:
I. Current Organizational Affiliations: Including remunerated and
voluntary activities with government agencies,
industry and business, academic institutions, foundations, as a consultant, officer, owner, trustee, manager, or
teacher/professor. E.g. advisory board appointments, external teaching appointments, or adjunct status at
another institution. Please explain aspects of these activities that may be pertinent to your MBL
responsibilities. For example, provide the title of your position and/or description of your role, approximate
number of hours and/or days worked, if you are remunerated, and the level of your remuneration. If additional
space is needed, a Word document may be attached.
Organization
Type of Business
Remuneration
Effort –
Hrs/Year
1.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
2.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
3.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
4.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
II. Significant financial interests– List all organizations doing business with the MBL or whose business is
substantially related to your institutional responsibilities at the MBL from which you receive salary or other
compensation (royalties, licensing fees from patents, copyrights, etc.) greater than $5,000 for the preceding 12
months; or in which you have equity interests (stocks, options or other ownership interests) valued at $5,000 or
more; or 5% or more ownership interests. This includes aggregate financial interests of yourself and your
immediate family members (spouse, domestic partner, and/or dependent child/ren). Equity held via mutual funds,
pension funds, etc., are excluded. You may also exclude income from seminars, lectures, or teaching, and
service on advisory committees or review panels, for public (governmental) or non-profit entities.
COI_8.19.2019AC.docx | PAGE 2
Organization
Type of Business
Remuneration
Effort –
Hrs/Year
1.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
2.
Govt Non-Profit
For Profit Private
For Profit:Public
None
$1-4,999
$5,000+
Details of affiliation:
III.Additional Information:Briefly describe any other professional or personal circumstances or activities that in
your opinion might be reasonably construed as having a potential impact on your judgment about your official
MBL responsibilities.
____________________________________________________________________________________________
Please acknowledge the three statements below (if you are a course director or an adjunct scientist with
MBL, please acknowledge the first two statements only) and sign the form.
_____ I have read and understand this Policy and, to the best of my knowledge, I have no affiliation with any
organization or activity other than listed above that could be construed as constituting a conflict of interest with the
MBL, as defined in the MBL's Conflict of Interest Policy.
_____ If, during the course of the year, my affiliations or significant financial interests should change, I will notify
the Director of Sponsored Programs and Research Administration within 30 days or in any event before any new
research proposal is submitted or before any more funds are expended from an existing award.
_____ I certify that I have worked less than 52 days total in the past year on outside activities as specified in the
details above.
_____________________
Date
_____________________
________________________________________________
Signature
Reviewed By:
__________________________________________________
Director of Research Administration and Sponsored Programs Date
Date of Compliance Committee review: __________________________
Comments, if any action taken: _____________________________________________________________
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MARINE BIOLOGICAL LABORATORY CONFLICT OF INTEREST DISCLOSURE Privileged (Marine Biological Laboratory)

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Completed 16 August 2020

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