CONFIDENTIAL
Significant Financial Interest Form
Reason for completing form (check one)
New Proposal Submission Annual Disclosure Acquisition of new SFI
Investigator newly added to existing project Previously existing, undisclosed SFI
Question 1: Have you completed the required CITI Conflict of Interest training?
Response: No. Please sign into CITI and complete training; Yes. Please go to question 2.
Question 2: During the last 12 month period, did you, your spouse, domestic partner, and/or dependent children, alone
or in combination have significant financial interest which may reasonably
appear related to the
Investigators Institutional responsibilities where:
• Remuneration from a publicly traded entity when aggregated is in excess of $5,000. Remuneration includes
salary (consulting fees, honorarium, etc.) or equity interest (stock, stock options, or other ownership interests
determined at fair market value).
• Remuneration from any non-publicly traded entity when aggregated is in excess of $5,000 or when equity
interest (stock, stock options, or other ownership) is held.
• Intellectual property rights and interest (e.g., patents, copyrights), upon receipt of income related to suc
h
i
nterests, is paid by an entity other than the Institution.
• Sponsored travel paid or reimbursed, in any amount, on behalf of the Investigator (not to the Investigator)
unless paid by an Excluded Payer (according to UWG policy).
Response:
No. Your disclosure is complete. Please sign and submit this form with your CITI training certificate.
Yes. Sign this form and attach a Financial Conflict of Interest Disclosure form.
By checking above I certify that I have completed this disclosure to the best of my knowledge and belief. I have read the UWG
Financial Conflict of Interest Policy and completed the required training. I understand and agree that if there is a material
change in significant financial interest, I will submit a new disclosure and attachment within 30 days of that change.
Signature Date
Significant Financial Interest does not
include:
• Salary, royalties, or other remuneration received from or through the University.
• Intellectual property rights assigned to the University and agreements to share in royalties related to such rights.
• Income from seminars, lectures, or teaching engagements sponsored by governments, institutions of higher education, academic
teaching hospitals, medical centers or research institutes affiliated with institutions of higher education.
• Income from service on advisory committees or review panels for governments, institutions of higher education, academic
teaching hospitals, medical centers or research institutes affiliated with institutions of higher education.
•
Investments in and income from investment vehicles, such as mutual funds and retirement accounts as long as the employee does
not directly control the investment decisions made in these vehicles
.
Please return this form to: charlac@westga.edu
Principal Investigators should attach a list of all other investigators responsible for the design,
conduct, or reporting of research for this project.
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