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Conflict of Interest Investigator Financial Disclosure Statement
I certify that I have read the Financial Disclosure Policy on the Ȧ Office of Sponsored Programs (OSP) website HYPERLINK "http://www.ric.edu/osp/Pages/Research-Policies-and-Procedures.aspx" http://www.ric.edu/osp/Pages/Research-Policies-and-Procedures.aspx which is effective for all external proposals submitted through the College. I have completed The Financial Conflict of Interest online training through CITI. A copy of the CITI completion certificate is attached.
FORMCHECKBOX I certify to the best of my knowledge that neither I, nor my spouse, partner, or dependents hold any significant financial interests that would reasonably be affected by the research, educational or creative activities proposed for, or currently supported by external funding, or in any entities whose financial interests would reasonably be affected by such activities.
FORMCHECKBOX I have relationships, affiliations, activities, or interests (financial or otherwise) which constitute potential conflicts under federal conflict of interest regulations. I have submitted a completed Financial Disclosure Form HYPERLINK "http://www.ric.edu/osp/Pages/Research-Policies-and-Procedures.aspx" http://www.ric.edu/osp/Pages/Research-Policies-and-Procedures.aspx to the colleges Research Integrity Officer (RIO Director, OSP) for any potential conflicts that may be Significant Financial Interests.
If any situations arise of w h i c h I a m a w a r e , t h a t a r e c o n t r a d i c t o r y i n a n y w a y t o t h e a b o v e s t a t e m e n t , I w i l l i m m e d i a t e l y n o t i f y t h e R I O a n d m a k e f u l l d i s c l o s u r e o f a n y c o n f l i c t , r e a l o r p o t e n t i a l .
N a m e : _ F O R M T E X T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
T i t l e o f P r o p o s a l : _ F O R M T E X T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
S p o n s o r : _ F O R M T E X T _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I n v e s t i g a t o r S i g n a t u r e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e: __________________
RIO Designee Signature: ______________________________________ Date: __________________
Investigator is the project director/principal investigator and any other person(s), regardless of title or position, responsible for design, conduct or reporting of externally funded research or proposing such funding. Regulations apply to collaborators, consultants, post-doctoral fellows, graduate students and others, as well as any individual meeting definition of investigator at awardee and subrecipient organizations. Each individual meeting this definition of investigator must complete this Financial Disclosure Statement.
Exclusions:
The 2011 revised regulation modifies the types of interests that are specifically excluded from the Significant Financial Interest definition. Exclusions are:
salary, royalties, or other remuneration paid by the Institution to the Investigator if the Investigator is currently employed or otherwise appointed by the Institution;
intellectual property rights assigned to the Institution and agreements to share in royalties related to such rights;
any ownership interests in the Institution held by the Investigator, if the Institution is a commercial or for-profit organization;
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;
income from seminars, lectures, or teaching engagements sponsored by a federal, state, or local government agency, an Institution of higher education as defined in 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;
income from service on advisory committees or review panels for a federal, state, or local government agency, or an Institution of higher education as define Z - . / q r s J
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ThisDocument T h i s D o c u m e n t
F Microsoft Word 97-2003 Document
MSWordDoc Word.Document.8 9q P R O J E C T w m ) C o m p O b j r