ࡱ> =?<y $bjbj .6{{1**8,...DDD$\DDpDD:,Dмv 0.  .* J: Western University of Health Sciences CONFLICT OF INTEREST DISCLOSURE FORM To be completed and filed by all investigators before submitting proposals to federal agencies requiring disclosures or if answers to any question on potential conflict of interest is yes. Important: See page two of this form for the definition of investigator and other terms according to federal regulations. Please submit completed form to Traci Meyer at 909-469-8334, or  HYPERLINK "mailto:tracim@westernu.edu" tracim@westernu.edu . Section A Name ___________________________________ University Address ___________________________ Title ____________________________________ Role on Project ______________________________ Office Telephone __________________________ E-Mail Address _____________________________ Have you completed the required Financial Conflict of Interest Training _____ YES _____NO If YES, please include a copy of your Certificate of Training to Sponsored Research If NO, please contract Traci Meyer for assistance. (x8334) Do you, your spouse, any dependent children, and/or any Associated Corpus in aggregate have Significant Financial Interests (1) that would reasonably appear to be affected by any of your Institutional Responsibilities including but not limited to activities funded or proposed for funding by the National Institutes of Health, National Science Foundation or Public Health Service; or (2) in Entities not controlled by the University whose financial interests would reasonably appear to be affected by such activities? _______ YES _______ NO Please sign below to certify (1) that you have fully and to the best of your ability completed this disclosure form (including, if you answered YES to question 2, separate entries for each relevant entity on photocopied duplicates of Section B below), and (2) that you will update your disclosure form promptly if relevant circumstances change. Signature ________________________________________ Date ____________________________________________ Section B (To be completed only if answer is yes to Question 2) Name of Entity ___________________________________________________________________________ Activity or product of entity related to current or prospective university-based research or educational activities: _________________________________________________________________________________________ Nature of the Significant Financial Interest to you or your family: _______ Participation as employee(s) _______ Equity interest in Non-Publicly traded entities _______ Consulting or occasional lecturing _______ Honoraria _______ Travel Reimbursement _______ Service on Advisory or Directors Boards _______ Writing commissioned papers or reports _______ Payments, through Westerns distribution plan, of royalties on patents and copyrights, etc. _______ Payments, not through Westerns royalty distribution plan, for intellectual property rights _______ Other (___________________________________________________________________) Approximate dollar value of the interest: _______ $0- $4,999 ________ $40,000 59,999 _______ $5,000 - 9,999 ________ $60,000 79,999 _______ $10,000 19,999 ________ $80,000 99,999 _______ $20,000 39,999 ________ $100,000 150,000 ___ For amounts greater than $150,000, estimate the amount to the nearest increment of $50,000. ___ The interest is one whose value cannot be readily determined through reference to public prices or other reasonable measures of fair market value. Elaboration of answers to previous questions and description of steps already taken, or being taken, to oversee and/or manage potential conflicts of interest: (Attach additional pages if necessary) Western University of Health Sciences CONFLICT OF INTEREST DISCLOSURE FORM OPERATING DEFINITIONS According to the National Institutes of Health (NIH), National Science Foundation (NSF) and Public Health Service (PHS) regulations: The term significant financial interest (SFI) signifies anything of monetary value, including but not limited to, salary or other payments for services (e.g., consulting fees or honoraria); equity interests (e.g., stocks, stock options or other ownership interests); and intellectual property rights (e.g., patents, copyrights and royalties from such rights). All SFI related to the Investigators institutional responsibilities must be disclosed. The term does not include: Salary, royalties or other remuneration from Western University of Health Sciences; Income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities including a 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 research institution that is affiliated with an institution of higher education; Income from service on advisory committees or review panels for public or nonprofit entities including a 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 research institution that is affiliated with an institution of higher education; An equity interest that when aggregated for the investigator and the investigators spouse and dependent children, meets both of the following tests: Does not exceed $5,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and does not represent more than a 5% ownership interest in any single entity; or Salary, royalties or other payments that when aggregated for the investigator and the investigators spouse and dependent children over the next twelve months, are not reasonably expected to exceed $5,000. Income from investment vehicles, such as mutual funds and retirement accounts as long as the Investigator does not directly control the investment decisions made in these vehicles. The term investigator signifies the principal investigator, co-principal investigators, and any other person at the institution who is responsible for the design, conduct, or reporting of research or educational activities funded or proposed for funding by NIH, NSF or PHS. In addition: The term associated corpus signifies any trust, organization or enterprise other than the University over which investigators, singly or collectively with members of their households, and/or immediate family, exercise a controlling interest. The term entity signifies any legal body created for profit or charitable purposes. Travel reimbursements and sponsored travel: Disclose the occurrence of any reimbursed travel or sponsored travel related to Institutional Responsibilities (including purpose of trip, sponsor/organizer, destination and duration). NOT REQUIRED to disclose travel that is reimbursed or sponsored by a 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. The University will determine if any travel requires further investigation, including determination or disclosure of the monetary value.     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