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CALIFORNIASTATEUNIVERSITY,EASTBAY
OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP)
NSFCONFLICTOFINTERESTDISCLOSUREFORM
(RequiredforallproposalssubmittedtotheNationalScienceFoundationandanyotherentitiesthathaveadoptedthisrequirement)
THISSUBMITTALisforaNewDisclosureUpdatedDisclosure
Investigator’sName:
AcademicDepartment:
Proposal/ProjectTitle:
AwardNumber:
ProposalType(pleasecheckone):
NationalScienceFoundation(NSF)
Subawardfrom__________________________underNSFPrime
Other:_________________________________
Atthetimeaproposalissubmitted,PrincipalInvestigators(PIs),ProjectDirectors(PDs),andanyotherindividualswithresponsibilityfor
design,conduct,orreportingofaproject(“CoPI’s”,"Subcontractors")mustdiscloseSignificantand/orRelatedFinancial
Interestsof
themselves,theirspouse,anddependentchild(ren)wherethatfinancialinterestmaybe:1)affectedbytheresearchbeingconductedor,
2)inanyorganizationthatwouldreasonablyappeartobeaffectedbyorbenefitfromtheresearchbeingconducted.
ThisrequirementappliestoproposalstotheNationalScience
Foundation(NSF)ortoanyotherentitythathasadoptedtherequirements.
Applicationextendstosubawardproposals/awardiffundingwillcomefromNSForfromanyotherentitythathasadoptedthe
requirements.
NOTE:ThisdisclosureisseparatefromanydisclosurerequiredunderStateofCaliforniaAdministrativeCode,Title2,
Section18705(Form
700UStatementofEconomicInterestsforPrincipalInvestigators).
SignificantFinancialInterest(SFI)isdefinedasanythingofmonetaryvalueincluding,butnotlimitedto:
Salary,income,honoraria,royalties,dividends,consulting,loans,orotherpaymentorconsiderationwithvaluefromanybusiness,
public,ornonprofitentity
exceeding$10,000duringthepriortwelvemonths,aggregatedfortheInvestigator,spouse,and
dependentchild(ren).
Equityinterest(stock,stockoptions,realestate,etc.)thatexceeds$10,000or5%ownership.
Equityinterest(stock,stockoptions,realestate)thatexceeds$10,000or5%ownership.
Managementpositionsuchasboardmember,
director,officer,partner,ortrusteeheldbytheInvestigator.
IntellectualpropertyinterestheldbytheInvestigator,spouse,anddependentchild(ren)assignedortobeassignedtoapartyother
thantheCSUChancellor’sOffice.
*Donotinclude:(1)Salary,royalties,orotherremunerationfromtheuniversity;(2)Incomefromseminars,lectures,orteachingengagementssponsored
bypublicornonprofitentities:(3)incomefromserviceonadvisorycommitteesorreviewpanelsforpublicornonprofitentities.
RelatedFinancialInterest(RFI)isdefinedasworkperformedunderasponsoredproject,whichresultswouldappeartoaffecttheInvestigator's
SFI;thefollowingareconsideredRFis:
ResultsofprojectbeingcarriedoutbyInvestigator,whichwouldberelevanttodevelopment,manufacturing,orimprovementof
productorserviceofentity
inwhichInvestigatorhasaSFI.
Investigatorfinancialinterestinanentity,whichmightmanufactureorcommercializedrug,device,procedure,oranyotherproduct
usedintheprojectorthatwillpredictablyresultfromtheproject.
Investigatorconsultingincomefromasingleentitythatexceeded$10,000duringthe
priortwelvemonths;andthefinancial
interestsofthatentity,ortheInvestigator'sfinancialinterestrelatedtoconsultingforthatentity,wouldreasonablyappeartobe
affectedbytheresearchtobeconducted.
Entitywherefinancialinterestslieisproposedasasubcontractor,consortiummember,supplierofgoods,lessor,or
otherwise
involvedwiththesponsoredproject.
DisclosureisrequiredatthetimeanewproposalissubmittedandwheneverthereisadisclosablechangeintheSFIorRFIofan
Investigator,spouse,ordependentchild(ren),asdefinedabove.
Seehttp://www20.csueastbay.edu/orsp/files/docs/policyandregulations/Conflict%20of%20Interest%20PolicyCR3.pdfforthePolicyon
DisclosureofFinancialInterestsRelatedtoSponsoredProjectsandforotherinformation.
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AllInvestigatorsmustanswerthefollowingquestion:
Doyou,yourspouse,ordependentchild(ren)haveanySignificantandRelatedFinanciallnterest(s)thatwould(i)reasonablyappearto
beaffectedbytheresearchforwhichfundingissoughtor,(ii)areinthesponsoroftheresearchor(iii)arein
entitieswhosefinancial
interestswouldreasonablybeaffectedbytheresearch?
NOYES
IfyouansweredNO,pleasesignthisform(onthelastpage)andsubmitwithyourproposal.
IfyouansweredYES,pleaseanswerthefollowingquestions(attachseparatesheetifneeded),signandsubmitwith
yourproposal.
NameofEntity:
PrincipalBusinessofEntity:
1.Ifyou,yourspouse,ordependentchild(ren)holdapositionofmanagementwiththisEntity,statethepositiontitle,describe
theresponsibilitiesofthepositionandexplainanyrelationshiptothisproject.
2.Ifyou,yourspouse,ordependentchild(ren)haveequityinterestinexcessof$10,000
or5%ownershipinEntity,statethevalue,
typeofequity(stock,securities,etc.),andpercentageofownership.
3.Ifyou,yourspouse,ordependentchild(ren)havereceivedincomeinexcessof$10,000fromtheEntityinthepast12months,describe
thenatureoftheincomeand
explainanyrelationshiptothisproject.
4.Haveyou,yourspouse,ordependentchild(ren)assignedtotheEntityrightstoapendingapplicationorissuedpatenttoan
invention(s),licenserights,orcopyrightforsoftware(donotincludeCSUheldrights)?
No
Yes:Theapplication,patent,or
licenseisNOTfromtheUniversity.
5.IfthisproposalincludestheEntityasasubcontractor,consortiummember,supplierofgoods,lessororotherwiseinvolvedinthe
project,explainanddescribe.
6.IftheEntitymightmanufactureorcommercializeanydrug,vaccine,device,product,procedure,orprocess
thatisassociatedwithor
thatwillpredictablyresultfromtheproject,explainanddescribe.
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7.IftheEntitycouldbereasonablyexpectedtobedirectlyandsignificantlyaffectedbythedesign,conduct,orreportingofthe
activityproposed,explainanddescribe.
8.Isitreasonabletoanticipatethatyourfinancialinterestcouldbedirectlyandsignificantlyaffectedbythedesign,conduct,or
reporting
oftheactivityproposed?
No:Explain.
Yes:Explain.
9.AdditionalComments.Attachseparatesheetifnecessary.
Certificationbyindividualfilingdisclosure
IcertifythatthisisacompletedisclosureofallfinancialinterestsrelatedtothisEntity.
Signature:
Date:
Theinformationprovidedonthisformmay,undertheCaliforniaPublicRecordsAct,bereleasedtosponsoringagencypersonnelormembers
ofthepublic.ThepurposeofcollectingthisinformationistocomplywithfederalregulationsandtheUniversityPolicyonDisclosureof
FinancialInterestsrelatedtoSponsoredPrograms.
CompleteoneformforeachEntityinwhichyouhaveafinancialinterest.
Retention:Five(5)yearsafterterminationofsponsoredprojectoruntilresolutionofanyactionbythesponsor,whicheverislonger.
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