Virginia State University Financial Interests Report
(submitted pursuant to the requirements of the Virginia State University Conflict of Interest policy at
http://www.vsu.edu/research/research-compliance/responsible-conduct-of-research.p
hp)
)
Name: ____________________________________________
I am reporting on activities: for the year ______
as an addendum to my most recent report
yes
no
1. Compensation (including travel expenses). Have you
or a member of your Family
received compensation from a for-profit entity for activities such as consulting, expert
witness, advisory board membership, and the like? If yes, furnish information on an
additional page.
yes
no
2. Equity. Do you or a member of your family own stock or hold stock options with a
publicly-trade
d or privately-owned entity? If yes, furnish information on an additional
page.
yes
no
3. Role. Do you or a member of your family serve as a director, trustee, officer or other key
employee
in a for-profit corporation, partnership, business, or other entity outside of
Virginia State University. If yes, furnish information on an additional page.
yes
no
4. Intellectual Property. Do you or a member of your family have rights to and/or receive
royalti
es from intellectual property (including, patents copyrights and trademarks but
excluding academic or scholarly works) licensed to and/or owned by a for-profit entity?
Do NOT include intellectual property owned or managed by Virginia State University. If
yes, furnish information on an additional page.
Certification:
I have read and understand Virginia State University
’s policy on Conflicts of Interest in Federally-Funded
Projects at http://www.vsu.edu/research/research-compliance/responsible-conduct-of-research.php
and have completed this report to the best of my knowledge and belief. If required, I will comply with any conditions
or restrictions imposed by Virginia State University to manage any real or perceived conflicts. Should my outside
financial or managerial interests, or those of my Family, change in a way that results in different answers to any of
the questions asked in this report, I agree to submit a revision.
_____________________________ ______________________________________________________
(date) (signature)
additional page(s) attached
