Montana State University
Conflict of Interest
Research Disclosure Statement
Department
Date
Disclosure
I am disclosing the following significant financial interests as defined in the MSU Conflict of Interest Policy
(including those of my spouse and dependent child(ren)) and attaching a written explanation that identifies
the business enterprise or entity involved and the nature and the amount of the interest: [check all that apply]
I am disclosing my participation as an employee, officer, board member, or owner in an entity which has (or
wishes to have) rights to intellectual property for which I was an invertor or creator in my work for MSU in the
included written explanation identifying the entity, intellectual property, and my position.
By submitting this form, I agree as follows:
I have read and understand the MSU Conflict of Policy.
I will update this disclosure during the pendency of this award on my annual disclosure form or any time a
new Significant Financial Interest is acquired.
I will cooperate in the development of a conflict management plan if determined to be necessary by the
University; and
I will comply with the conditions or restrictions imposed by the University to manage, reduce, or eliminate
actual or potential conflicts of interest or forfeit the award.
Include written explanation on Page 2
Page 1 of 2
This form is to be completed whenever a potential conflict of interest is identified on the Proposal Clearance
Form (PCF) and it must be attached to the PCF.
1. Save this form on your computer.
2. Fill out the entries using Adobe Reader or Acrobat and save the information in the form.
3. If you are using the electronic proposal clearance form, you must attach the completed statement
as a Conflict of Interest file on the Review Boards page. If you are submitting a paper proposal
clearance form, print the document, sign it, and attach it to the paper form.
Signature
Project Dir/PI
Project Title
Position
Name
Sponsor
Form Date 08.24.2012
Salary or other payment for services (e.g., consulting fees, or honoraria)
Ownership interests (e.g., stock, stock options, partnership interest, or other)
Intellectual property rights (e.g., patents, copyrights, or royalties)
Anything else of monetary value that reasonably relates to my Institutional Responsibilities
Please describe below the relationship between the interest reported and your institutional
responsibilities at Montana State University.
