Fill - Free fillable PHSFINANCIALDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalInstitutesofHealthandanyotherentitiesthathaveadopt PDF form

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CALIFORNIASTATEUNIVERSITY,EASTBAY

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

PHSFINANCIALDISCLOSUREFORM

(RequiredforallproposalssubmittedtotheNationalInstitutesofHealthandanyotherentitiesthathaveadoptedtheirrequirements)



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InstitutesofHealth(NIH)/PublicHealthandServices(PHS)

Subawardfrom__________________________underNIH/PHSPrime

Other:_________________________________



InaccordancewiththeCSUEBPolicyonDisclosureofFinancialInterestsandManagementofConflictsofInterestRelatedtoPubli c

HealthServicesSponsoredAwardsforResear ch(42C.F.Part50,

SubpartFand45C.F.R.,Part94),thePrincipalInvestigatorandall

otherCo‐Investigatorsmustdisclosetheirpersonalsignificantfinancialinterests(andthoseoftheirspouse/registereddomesticpartner

and/ordependentchildren)relatedtotheirinstitutionalresponsibilities.ThisincludesthePrincipalInvestigator,Co‐Investigators,Senior

andKeyPersonnel,andanyother

individualwhoisresponsibleforthedesign,conduct,orreportingofresearchfundedbyPHSoran

agencyororganizationthatfollowsPHSdisclosurerequirements(forexample,AmericanHeartAssociation,AmericanCancerSociety,

etc.).



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).



1. Anypersonwhoisresponsibleforthedesign,conduct,orreportingofthePHS‐fundedresearchprojectmustsubmitthePHSFinancial

DisclosureFormatthetimeofproposalsubmission.

2. Atthejust‐in‐timestageofawardingprocess,ConflictofInterest(COI)staffwillcontactInvestigatorswhohavedisclosed

anysignificant

financialinterests(SFI)torequestthesubmissionofthePHSFinancialDisclosureForm.TheCOIDesignatedOfficialwillreviewFormto

determinewhetherornotthedisclosedSFIisrelatedtotheresearchproject.

3. TheCOIStaffwillcontacttheInvestigatorswhohaveSFIrelatedtothe

PHS‐fundedresearchprojecttorequestthesubmissionofPHS

FinancialDisclosureFormforConflictofInterestCommitteereview.

4. TheConflictofInterestCommitteewillconsiderwhethertheInvestigator’sSFIcoulddirectlyandsignificantlyaffectthedesign,conduct,

orreportingofthePHS‐fundedresearchproject.Pleaseallowsufficienttime

forCommitteereview.

5. SubmissionofPHSFinancialDisclosureFormisrequired(i)onanannualbasisfornon‐competingcontinuationawards,(ii)whenanew

Investigatorisaddedtotheproject,or(iii)whenanInvestigator’sfinancialinter estsincrease,whichevercomesfirst.Itisalsorequiredwhen

anInvestigator

transfersPHS‐fundedresearchtoCSUEastBay.



Whoisconsideredan“Investigator,”andthereforerequiredtodisclose?“Investigator”meanstheprojectdirectororprincipalinvestigator

andanyotherperson,regardlessoftitleorposition,whoisresponsibleforthedesign,conduct,orreportingofresearchfundedbythePHS

(e.g.,NIH),orproposedforsuchfunding.



Whatisanentity ?Entitymeansanydomesticorforeign,p ublicorprivate,organization(excludingaFederalagency)fromwhichan

Investigator(andspouseanddependentchildren)receivesremunerationorinwhichanypersonhasanownershiporequityinterest.



Whatis

a“SignificantFinancialInterest”?Asignificantfinancialinterestconsistingofoneormoreofthefollowinginterestsofthe

Investigator(andthoseoftheInvestigator’sspouseanddependentchildren)thatreasonablyappearstoberelatedtotheInvestigator’s

institutionalresponsibilities:

1. Withregardtoanypubliclytradedentity,anyincome

receivedfromentityin12monthsprecedingdisclosureandvalueofanyequity

interestsinentityasofdateofdisclosureexceeding$5,000whenaggregatedforanInvestigator,Investigator’sspouse,anddependent

childrenfromasingleEntity(Business,PublicorNonprofit)includingsalary,consultantpayments,honoraria,royaltypayments,dividend,

loan,

oranyotherpaymentsorconsiderationwithvalueduringthepriortwelvemonths.Equityinterestincludesanystock,stockoption,or

otherownershipinterest,asdeterminedthroughreferencetopublicpricesorotherreasonablemeasuresoffairmarketvalue;

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2. Withregardtoanynon‐publiclytradedentity,anyremunerationreceivedfromentityin12monthsprecedingdisclosure,when

aggregated,exceeds$5,000;orwhenInvestigatorholdsanyequityinterest(e.g.,stock,stockoption,orotherownershipinterest).Exclude

incomefromseminars,lectures,orteachingengagementssponsoredbyaU.S.

Federal,state,orlocalgovernmentagency,aninstitutionof

highereducationasdefinedat20U.S.C.1001(a),anacademicteachinghospital,amedicalcenter,oraresearchinstitutethatisaffiliated

withanInstitutionofhighereducation;

3. IntellectualpropertyinterestheldbytheInvestigator,orInvestigator’sspouseordependentchildren

onapatent,patentapplication,or

acopyrightofsoftwareassignedortobeassignedtoapartyotherthantheCSUuponreceiptofincomerelatedtosuchrightsandinterests

thatexceed$5,000in12monthsprecedingdisclo sure.

4. Anyreimbursedorsponsoredtravelinexcessof$5,000

perentityinthe12monthspriortodisclosure(i.e.,thatwhichispaidonbehalf

ofInvestigatorandnotreimbursedtoInvestigatorsothattheexactmonetaryvaluemaynotbereadilyavailable),relatedtoinstitutional

responsibilities.ExcludestravelreimbursedorsponsoredbyaU.S.Federal,state,orlocalgovernment

agency,aninstitutionofhigher

educationasdefinedby20U.S.C.1001(A),anacademicteachinghospital,amedicalcenter,oraresearchinstituteaffiliatedwithInstitution

ofhighereducation.



Whatisnota“SignificantFinancialInterest”?Significantfinancialinterestsdonotinclude(1)payments(salary,royalties,honoraria,

expensereimbursementoranyotherremuneration)or(2)incomefromseminars,lectures,orteachingengagementssponsoredbyaU.S.

Federal,state,orlocalgovernmentagency,aninstitutionofhighereducationasdefinedat20U.S.C.1001(a),anacademicteachinghospital,

amedicalcenter,oraresearchinstitutethatisaffiliatedwith

anInstitutionofhighereducationor(3)aninvestmentbyamutualfund,

pensionfundorotherinvestmentfundoverwhichtheinvestigatororhis/herimmediatefamilymemberdoesnotexercisemanagementof

fundinvestment.



Whatareinstitutionalresponsibilities?

“InstitutionalResponsibilities”isdefinedasteaching/education,research,outreach,clinicalservice,training

andUniversityandpublic

service,onbehalfofCSUEastBayanddirectlyrelatedtothosecredentials,expertiseandachievementsuponwhichtheInvestigator’sCSUEB

positionisbased.



Records

Theinformationprovidedhereinmaybereleasedortransmittedtothesponsor,includingFederalagencyrepresentatives,andaccordingto

the

CaliforniaPublicRecordsAct,mayalsobereleasedtothepublic,uponrequest.Theserecordswillberetainedfor5yearsafter

term inationofsponsoredproje ctoruntilresolutionofanyactionbythesponsor,whicheverisgreater.TheOfficeofRecordistheResearch

AdministrationandComplianceOffice.



See

http://www20.csueastbay.edu/orsp/files/docs/policy‐and‐regulations/supplemental‐phs‐coi‐2014.pdfforthePolicyonDisclosureof

FinancialInterestsRelatedtoSponsoredProgramsandforotherinformation.



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

Forthepurposeofthisdisclosureform,InstitutionalResponsibilitiesmeansanInvestigator’steaching/education,research,outreach,

clinicalservice,andUniversityandpublicserviceonbehalfofCSUEBwhichareinthecourseandscope

oftheInvestigator’sCSUEB

appointment/employment.



1.PubliclyTradedEntity

IncomeandEquityInterests

Haveyou,yourspouseorregistereddomesticpartner,and/ordependentchildrenreceivedincomeorpaymentforservicesinthepast12

monthsorownequityinterestinanypubliclytradedentityrelatedtoyourinstitutionalresponsibilitiesexceeding$5,000when

aggregated?Thisdoesnotincludeinterestsinmutual

fundsandretirementfundsinwhichyoudonotdirectlycontrolinvestment

decisions.

NOYES

2.Non‐PubliclyTradedEntity

Income

Haveyou,yourspouseorregistereddomesticpartner,and/ordependentchildrenreceivedincomeorotherpaymentforservices,inthe

past12months,exceeding$5,000,whenaggregated,fromanynon‐publiclytradedentity?ThisdoesnotincludepaymentsfromtheCSU

Chancellor’sOffice,orincomefromseminars,lectures,orteaching

engagementssponsoredbyaU.S.federal,state,orlocalgovernment

agency,aU.S.institutionofhighereducationoranaffiliatedresearchinstitute,anacademicteachinghospital,oramedicalcenter.



NOYES

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

EquityInterests

Doyou,yourspouseorregistereddomesticpartner,and/ordependentchildrencurrentlyown,orhaveacquiredinthepast12months,

anyequityinterestinanynon‐publiclytradedentityrelatedtoyourinstitutionalresponsibilities?Thiscanincludeanystock,stockoptionor

otherownershipinterest.

NO

YES



3.IntellectualPropertyRightsandInterests

Haveyou,yourspouseorregistereddomesticpartner,and/ordependentchildrenreceivedanypayments,inthepast12months,forany

intellectualpropertyrightsandinterests(e.g.patents,copyrights,assignedorlicensedtoapartyotherthantheCSU)exceeding$5,000

relatedtoyourinstitutionalresponsibilities?

NOYES



4.TravelReimbursement/Sponsorship

Haveyoureceivedtravelreimbursementorbeensponsoredfortravel(i.e.travelexpensespaidonbehalfofInvestigatorandnot

reimbursedtoInvestigator)inexcessof$5,000perentityinthe12monthspriortodisclosure,byanyentityrelatedtoyourinstitutional

responsibilities?Thisdoesnotincludetravelsponsoredor

reimbursedbyaU.S.federal,state,orlocalgovernmentagency,aU.S.

institutionofhighereducationoranaffiliatedresearchinstitute,anacademicteachinghospital,oramedicalcenter.

NOYES



5.AcknowledgmentandCertification

Icertifyunderpenaltyofperjurythatthisisacompletedisclosureofallmysignificantfinancialinterestsrelatedtomyinstitutional

responsibilitiesandIhaveusedallreasonablediligenceinpreparingthisFinancialInterestDisclosure,andtothebestofmyknowledgeitis

trueandcomplete.Ialsoacknowledge

thatbysigningmynamebelowthatitismyresponsibilitytodisclose,within30days,anynew

significantfinancialinterestsobtainedduringthetermoftheaboveproposedproject.



Signature:



Date:

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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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PHSFINANCIALDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalInstitutesofHealthandanyotherentitiesthathaveadoptedtheirrequirements) THISSUBMITTALisforaNewDisclosureUp

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Fillable PHSFINANCIALDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalInstitutesofHealthandanyotherentitiesthathaveadopt

Fill Online, Printable, Fillable, Blank PHSFINANCIALDISCLOSUREFORM CALIFORNIASTATEUNIVERSITY,EASTBAY OFFICEOFRESEARCHANDSPONSOREDPROGRAMS(ORSP) (RequiredforallproposalssubmittedtotheNationalInstitutesofHealthandanyotherentitiesthathaveadopt Form

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