Fill - Free fillable NSFCONFLICTOFINTERESTDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalScienceFoundationandanyotherentitiesthath PDF form

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CALIFORNIASTATEUNIVERSITY,EASTBAY

OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP)

NSFCONFLICTOFINTERESTDISCLOSUREFORM

(RequiredforallproposalssubmittedtotheNationalScienceFoundationandanyotherentitiesthathaveadoptedthisrequirement)



THISSUBMITTALisforaNewDisclosureUpdatedDisclosure

Investigator’sName: 

AcademicDepartment: 

Proposal/ProjectTitle: 

AwardNumber: 

ProposalType(pleasecheckone): 

NationalScienceFoundation(NSF)

Subawardfrom__________________________underNSFPrime

Other:_________________________________



Atthetimeaproposalissubmitted,PrincipalInvestigators(PIs),ProjectDirectors(PDs),andanyotherindividualswithresponsibilityfor

design,conduct,orreportingofaproject(“Co‐PI’s”,"Subcontractors")mustdiscloseSignificantand/orRelatedFinancial

Interestsof

themselves,theirspouse,anddependentchild(ren)wherethatfinancialinterestmaybe:1)affectedbytheresearchbeingconductedor,

2)inanyorganizationthatwouldreasonablyappeartobeaffectedbyorbenefitfromtheresearchbeingconducted.



ThisrequirementappliestoproposalstotheNationalScience

Foundation(NSF)ortoanyotherentitythathasadoptedtherequirements.

Applicationextendstosubawardproposals/awardiffundingwillcomefromNSForfromanyotherentitythathasadoptedthe

requirements.



NOTE:ThisdisclosureisseparatefromanydisclosurerequiredunderStateofCaliforniaAdministrativeCode,Title2,

Section18705(Form

700‐UStatementofEconomicInterestsforPrincipalInvestigators).



SignificantFinancialInterest(SFI)isdefinedasanythingofmonetaryvalueincluding,butnotlimitedto:

 Salary,income,honoraria,royalties,dividends,consulting,loans,orotherpaymentorconsiderationwithvaluefromanybusiness,

public,ornonprofitentity

exceeding$10,000duringthepriortwelvemonths,aggregatedfortheInvestigator,spouse,and

dependentchild(ren).

 Equityinterest(stock,stockoptions,realestate,etc.)thatexceeds$10,000or5%ownership.

 Equityinterest(stock,stockoptions,realestate)thatexceeds$10,000or5%ownership.

 Managementpositionsuchasboardmember,

director,officer,partner,ortrusteeheldbytheInvestigator.

 IntellectualpropertyinterestheldbytheInvestigator,spouse,anddependentchild(ren)assignedortobeassignedtoapartyother

thantheCSUChancellor’sOffice.

*Donotinclude:(1)Salary,royalties,orotherremunerationfromtheuniversity;(2)Incomefromseminars,lectures,orteachingengagementssponsored

bypublicornonprofitentities:(3)incomefromserviceonadvisorycommitteesorreviewpanelsforpublicornonprofitentities.



RelatedFinancialInterest(RFI)isdefinedasworkperformedunderasponsoredproject,whichresultswouldappeartoaffecttheInvestigator's

SFI;thefollowingareconsideredRFis:

 ResultsofprojectbeingcarriedoutbyInvestigator,whichwouldberelevanttodevelopment,manufacturing,orimprovementof

productorserviceofentity

inwhichInvestigatorhasaSFI.

 Investigatorfinancialinterestinanentity,whichmightmanufactureorcommercializedrug,device,procedure,oranyotherproduct

usedintheprojectorthatwillpredictablyresultfromtheproject.

 Investigatorconsultingincomefromasingleentitythatexceeded$10,000duringthe

priortwelvemonths;andthefinancial

interestsofthatentity,ortheInvestigator'sfinancialinterestrelatedtoconsultingforthatentity,wouldreasonablyappeartobe

affectedbytheresearchtobeconducted.

 Entitywherefinancialinterestslieisproposedasasubcontractor,consortiummember,supplierofgoods,lessor,or

otherwise

involvedwiththesponsoredproject.



DisclosureisrequiredatthetimeanewproposalissubmittedandwheneverthereisadisclosablechangeintheSFIorRFIofan

Investigator,spouse,ordependentchild(ren),asdefinedabove.



Seehttp://www20.csueastbay.edu/orsp/files/docs/policy‐and‐regulations/Conflict%20of%20Interest%20Policy‐CR3.pdfforthePolicyon

DisclosureofFinancialInterestsRelatedtoSponsoredProjectsandforotherinformation.

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AllInvestigatorsmustanswerthefollowingquestion:

Doyou,yourspouse,ordependentchild(ren)haveanySignificantandRelatedFinanciallnterest(s)thatwould(i)reasonablyappearto

beaffectedbytheresearchforwhichfundingissoughtor,(ii)areinthesponsoroftheresearchor(iii)arein

entitieswhosefinancial

interestswouldreasonablybeaffectedbytheresearch?



NOYES



IfyouansweredNO,pleasesignthisform(onthelastpage)andsubmitwithyourproposal.

IfyouansweredYES,pleaseanswerthefollowingquestions(attachseparatesheetifneeded),signandsubmitwith

yourproposal.



NameofEntity:

PrincipalBusinessofEntity:



1.Ifyou,yourspouse,ordependentchild(ren)holdapositionofmanagementwiththisEntity,statethepositiontitle,describe

theresponsibilitiesofthepositionandexplainanyrelationshiptothisproject.



2.Ifyou,yourspouse,ordependentchild(ren)haveequityinterestinexcessof$10,000

or5%ownershipinEntity,statethevalue,

typeofequity(stock,securities,etc.),andpercentageofownership.



3.Ifyou,yourspouse,ordependentchild(ren)havereceivedincomeinexcessof$10,000fromtheEntityinthepast12months,describe

thenatureoftheincomeand

explainanyrelationshiptothisproject.



4.Haveyou,yourspouse,ordependentchild(ren)assignedtotheEntityrightstoapendingapplicationorissuedpatenttoan

invention(s),licenserights,orcopyrightforsoftware(donotincludeCSU‐heldrights)?

No

Yes:Theapplication,patent,or

licenseisNOTfromtheUniversity.



5.IfthisproposalincludestheEntityasasubcontractor,consortiummember,supplierofgoods,lessororotherwiseinvolvedinthe

project,explainanddescribe.



6.IftheEntitymightmanufactureorcommercializeanydrug,vaccine,device,product,procedure,orprocess

thatisassociatedwithor

thatwillpredictablyresultfromtheproject,explainanddescribe.

Page



7.IftheEntitycouldbereasonablyexpectedtobedirectlyandsignificantlyaffectedbythedesign,conduct,orreportingofthe

activityproposed,explainanddescribe.



8.Isitreasonabletoanticipatethatyourfinancialinterestcouldbedirectlyandsignificantlyaffectedbythedesign,conduct,or

reporting

oftheactivityproposed?

No:Explain.

Yes:Explain.



9.AdditionalComments.Attachseparatesheetifnecessary.



Certificationbyindividualfilingdisclosure

IcertifythatthisisacompletedisclosureofallfinancialinterestsrelatedtothisEntity.



Signature:



Date:



Theinformationprovidedonthisformmay,undertheCaliforniaPublicRecordsAct,bereleasedtosponsoringagencypersonnelormembers

ofthepublic.ThepurposeofcollectingthisinformationistocomplywithfederalregulationsandtheUniversityPolicyonDisclosureof

FinancialInterestsrelatedtoSponsoredPrograms.

CompleteoneformforeachEntityinwhichyouhaveafinancialinterest.

Retention:Five(5)yearsafterterminationofsponsoredprojectoruntilresolutionofanyactionbythesponsor,whicheverislonger.

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NSFCONFLICTOFINTERESTDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalScienceFoundationandanyotherentitiesthathaveadoptedthisrequirement) THISSUBMITTALisforaNewDisclo

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