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Faculty/Staff Name:
Department/Unit:
College/School:
Proposal Title:
Proposal Submitted to:
I have no Significant Financial Interests which would reasonably appear to be directly and significantly affected by the proposed external funding.
Signature: ____________________________________
Name Typed:
OR
I am disclosing the following significant financial interests (check one) and attaching documentation (in an envelope marked confidential) that identifies the business enterprise or entity involved and the nature and amount of the interest:
("Significant financial interests" are defined as interests or projected annual income valued at greater than $10,000 or an equity or ownership interest of more than five percent held by an Investigator or the Investigator's spouse or dependent children.)
_____ Salary or other payment for services (e.g., consulting fees or honoraria).
_____ Equity interests (e.g., stocks, stock options, or other ownership interests).
Further I agree:
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To update this disclosure during the period of the award as new reportable significant financial interests are obtained;
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To cooperate in the development of a conflict of interest "resolution plan."
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To comply with any conditions or restrictions imposed by the University to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award;
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To carry out these obligations prior to making any expenditures of sponsored project funds.
Signed: __________________________________ Date: __________
(Original signature only--a "per" signature is not acceptable.)
Endorsements:
I have reviewed the significant financial interest disclosure and believe that it will be possible, prior to expenditure of award funds, to manage, reduce or eliminate any actual or potential conflict of interest.
Designated Official:
Signed: __________________________________ Date: __________
Chair, Conflict of Interest ad hoc Committee:
Signed: __________________________________ Date: __________
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