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Conflict of interest2

Appendix A                                                                      

Conflict of Interest Form

 

Disclosure of Significant Financial Interests and Obligations

 

As part of its commitment to promoting objectivity in research and in compliance with federal regulations on conflict of interest, Worcester State University (WSU) has adopted a Policy on Conflict of Interest. This Policy requires that the investigators submit a disclosure form to ensure that the design, conduct and reporting of grant/sponsored program activity will not be biased by the significant financial interests or obligations of any investigator.  Investigators required to file include those in the roles of Principal Investigator, Co-Principal Investigator, project director, and any individual who is in a significant decision-making role or who has (or, if funded, will have) signature authority for a WSU grant account.  To comply with this Policy, each investigator must submit a Disclosure of Significant Financial Interests and Obligations before:

  • submission of an application to an external sponsor, or
  • acceptance of any award where there was no prior disclosure submitted for that work.

In addition, a revised Disclosure must be filed whenever an investigator’s significant financial interests and obligations change materially.

The Disclosure of Significant Financial Interests and Obligations is a two-part form.  All investigators must complete Part I.  If an investigator’s answers to Part I indicate that there may be a real or apparent conflict of interest, the investigator will also need to file Part II.

The completed Disclosure of Significant Financial Interests and Obligations should be placed in a sealed envelope, marked “Confidential,” and forwarded to the Grant Coordinator, Administration, Room 339B. The Grants Office will not submit your grant/sponsored programs application until your Disclosure form has been submitted. Compliance with this requirement is also a prerequisite to the acceptance of any grant.

The submission of this Disclosure satisfies the requirements of the Department of Health and Human Services (PHS & NIH) and the National Science Foundation (NSF). These agencies require that, by the time an application is submitted, each investigator planning to participate in PHS or NSF-funded research has disclosed his/her known significant financial interests (and those of his/her spouse and dependent children) (42 CFR Part 50 Subpart F and 45 CFR Part 94 and Section 510 of the NSF Grant Policy Manual).

Questions concerning this Policy should be addressed to Linda Crocker, Grant Coordinator, lcrocker@worcester.edu.  

 


Conflict of Interest Form

Disclosure of Significant Financial Interests and Obligations

Part I

All Worcester State University investigators seeking external sponsored funding to conduct scholarly activities or research are required to complete and file a signed Disclosure of Significant Financial Interests and Obligations. Each investigator must complete this form before a proposal can be endorsed for submission.

Specific Instructions: Place a check in the appropriate column for each question. Once every question is answered, the investigator must certify the information by signing the bottom of the form.

Investigator Name:                                                                                                                                               

Department/School:                                                                                                                                              

Questions

Yes

No

Do you, your spouse or dependent child(ren) hold a position of management, such as board member, director, officer, partner, trustee, employee or consultant with a sponsor, a vendor or (sub) contractor related to the sponsored program activity?

 

 

 

 

Do you, your spouse or dependent child(ren) have Significant Financial Interest in a Sponsor, a vendor or (sub) contractor related to your sponsored program activity?
“Significant Financial Interest” includes stock, stock options, and/or any other ownership interest in a single entity valued at more than $10,000 or 5% ownership.

 

 

 

 

 

Is it reasonable to anticipate that your financial interest could be directly and significantly affected by the design, conduct, or reporting of your sponsored program activity?

                 

 

 

                                                                                                               


If you answered “No” to ALL of the questions above, your Disclosure is complete; you do not have to submit Part II.  Please sign and date the certification below and forward to the WSC Grants Coordinator.

If you answered “Yes” to ANY question above, please complete a separate Part II for every outside organization with which you have the relationship(s) indicated above.

Investigator Certification:

  • I have read and understood the Policy on Conflict of Interest.
  • I agree to file a new or updated Disclosure of Significant Financial Interests and Obligations form if the answer to any of the above questions changes.
  • I certify that the answers to the declaration are accurate and truthful to the best of my knowledge.

 

 

Signature: __________________________________________                 Date: ________________________


Conflict of Interest Form

Disclosure of Significant Financial Interests and Obligations

Part II

 

Complete Part II only if you answered, "YES" to at least one of the questions in Part I.

Attach one Part II form for each organization with which you have the relationship(s) indicated in Part I.

Investigator Name:      ___________________________________________________________________

Number of Part II forms submitted:     , of which, this is number:      

1.      Name of organization:                                                                                                                                      

2.      Financial relationship(s) with the organization (check all that apply):

  Consultant                          Employee

  Equity Interest                    Recipient of Honoraria

  Recipient of Royalties        Other (Describe):                                                                                        

3.      The financial relationship is between the organization and (check all that apply):

  Self

  Spouse

  Dependent Child(ren)

 

4.              Have you received in the last twelve (12) months, or do you expect to receive in the next twelve (12) months, payments for salary, director's fees, consulting, honoraria, royalties, or any other payments that when aggregated with payments from this organization to your spouse and/or dependent child(ren) will exceed $10,000?     

Y  N

 

5.              Have you had in the last twelve (12) months or do you anticipate having in the next twelve (12) months, stock, stock options, or other equity interests in the organization which, when aggregated with those of your spouse and dependent child(ren) in this organization, have a fair market value exceeding $10,000 or represent an ownership interest of 5% or more?      Y  N

 

6.      What relationship, if any, is there between the business or activities of the organization and
your current or planned areas of research?           


Appendix B

Principal Investigator Certification on Investigator Conflict of Interest

for NSF or PHS (NIH) proposals

 

All investigators seeking National Science Foundation (NSF) or Public Health Service (PHS/NIH) support must disclose to their colleges/universities every significant financial interest that would reasonably appear to be affected by any grant/research for which NSF or PHS funding is sought. Principal Investigators (PI) accomplish this through the filing of the Disclosure of Significant Financial Interests and Obligations. Colleges/Universities must also have a written policy governing conflicts of interest which require disclosures by "each individual responsible for the design, conduct, or reporting of the research or educational activities funded or proposed for funding” by the agency. Funds may not be expended until identified conflicts have been managed or eliminated.

_____________________________________________________________________________

 

All three sections of this certification must be completed by the PI at the time of proposal submission. The original of this certification should be submitted with the proposal to the Grants Office. One copy should be retained with the Principal Investigator's records relating to the project.

___________________________________________________________________________________

 

1. Principal Investigator (PI)

PI name: _________________________________________________________________________

Funding agency          o NSF            o NIH/PHS

Title of proposal: ____________________________________________________________________

 

o A current Disclosure Form required for federal support is on file with the WSC Grant Office. All significant financial interests related to this proposal have been disclosed.

___________________________________________________________________________________

 

2. Are there other investigators? (check either A or B)

 

o A. No other individuals associated with this project bear responsibility for the design, conduct, or reporting of the proposed research; or

 

o  B. In addition to the Principal Investigator, the following individuals may be responsible for the design, conduct, or reporting of the proposed research. I have obtained a disclosure form from each. Forms indicating a potential conflict will be forwarded to the Grant Committee. Forms indicating no potential conflict will be retained with my records for a period of 3 years following the completion of the grant.

 

Other Investigator                   Form completed          Other Investigator                   Form completed

_____________________________ o                      _____________________________ o

_____________________________ o                      _____________________________ o

_____________________________ o                      _____________________________ o

___________________________________________________________________________________

 

3. Principal Investigator signature.

This signature indicates assurance by the Principal Investigator that s/he and all investigators have complied with federal and college requirements for disclosure of potential conflicts of interest relating to the grant/sponsored proposal identified above.

 

_________________________________________              ________________

Principal Investigator                                                 

Last modified at 5/31/2012 8:52 AM  by Hoxha, Anisa