Conflict of Interest Disclosure Form


Augusta University
(Applicable to all Sponsored Project Proposals and other significant individual and institutional conflicts of interest)

Name:  

Name and relationship of Family Member with Conflict (if applicable):     

Department/Unit:    

School/Unit:  

Proposal Submitted to (Sponsor):   

Proposal Title:  

A. Reason for Form: I am completing this form pursuant to one of the following:

_____ Institutional conflict of interest per Augusta University Institutional Conflicts of Interest Policy;

_____ Annual disclosure as required by Augusta University Individual Conflicts of Interest Policy;

_____ Update of my annual conflict of interest disclosure;

_____ In connection with my involvement as investigator in a proposal entitled:

 

  where the sponsor is:

PLEASE READ THE FOLLOWING CAREFULLY: Check this item ONLY IF you have no

reportable significant financial or other possible conflicts of interest pursuant to Augusta University Conflicts of Interest Policies.

 

_____ I HAVE NO SIGNIFICANT FINANCIAL OR OTHER SIGNIFICANT CONFLICT OF

INTEREST THAT I AM REQUIRED TO REPORT. If you check this item, then proceed to PART E, complete that section and submit this form to your Department or Unit Supervisor or Dean.

 

B. Type of Interest: I have read and understood the Conflicts of Interest Policies of the Georgia Health Sciences University. I am disclosing the following type of conflict of interest (check at least one) and attaching supporting documentation (in an envelope marked confidential) that identifies the business enterprise or entity involved and the nature and details of the interest:

 

1. Significant financial interest. Individual"s significant financial interests are defined as 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 interest); and intellectual property rights (e.g., patents, trademarks, copyrights and royalties from such rights). "Investigator" includes Investigator and the Investigator's spouse or

dependent children. [See Augusta University Conflict of Interest Policy for items not included.]

____ Salary or other payment for services (e.g., consulting fees or honoraria).

____ Equity interests (e.g., stocks, stock options, or other ownership interests).

____ Intellectual property rights (e.g., patents, trademarks, copyrights. and royalties from

such rights).

____ Other significant financial interest of the individual of family member that possibly could affect or be perceived to affect the results of the research or other scholarly activities funded or proposed for funding or other work on behalf of Augusta University. This interest is described as follows:

     

2. Other individual conflict of interest:  

  3. Institutional Conflict of Interest: 

 

C. Detailed information concerning significant financial interests (individual or institutional):

 

1. Please identify the business enterprise or entity (hereafter called "company") involved and the amount of the financial interest:

1a. Name of company: 

1b. Amount of financial interest: 

 

2a. Are you an officer of the company in which you have a financial interest?  

2b. If so, what are your responsibilities and how much time do you dedicate to this activity?

       

 

3a. Are you a member of the governing Board of Directors for the Company? 

3b. If so, please describe the general nature of the Board, your responsibilities, and your

time commitment as a board member:

        

 

4a. Are you a consultant for or otherwise compensated by the company for advice, lectures,

workshops, etc.?

4b. Please describe the activities for which you receive compensation: 

        

4c. Date and period the activity is conducted:

 

5a. Do you own stock in the company? 

5b. Number or percentage of shares owned:of possible  # or shares.

5c. Percentage of ownership:

5d. The stock is subject to (Check all that apply):

____ Anti-dilution provisions

____ Registration restrictions

____ Shareholders" agreements

5e. Is the stock publicly traded?  

 

6a. Does the company plan to submit proposals for federal funding?

6b. If so, is it for research which would be performed at Augusta University? 

6c. If so, is it for research that you would supervise at the company?

 

7a. Does the company intend to sponsor, from its own resources, any work at Augusta University?

7b. If so, will it be necessary or preferable for the work to be performed in your laboratory?

     

  

8. Describe the significance of the research identified in 5 or 6 above to any commercial

product that the company will sell or manufacture:

        

 

9a. Do you intend to involve any Augusta University student in your funded work?

9b. If so, for each student, please describe the nature of the work:

        

 

10. Please list all Augusta University faculty and staff who will assist you in this work and indicate whether

each individual has a potential conflict of interest:

Name:   Conflict?

          

       

 

 

11. If the study is a clinical trial, has this conflict of interest been disclosed to the IRB?

        

 

D. Proposed Resolution: Please describe to the members of the Augusta University Conflict of Interest

Panel the recommendations of you and your Chair for managing, resolving or eliminating the

potential conflict of interest described above.        

 

E. Further I agree and affirm:

" That I have read the Individual Conflicts of Interest and Institutional Conflicts of Interest

policies of Augusta University;

" That the above information is true to the best of my knowledge;

" That I will update this disclosure immediately if the circumstances above change during the

period of the award, either on an annual basis, or as new reportable significant financial

interests are obtained. In any event at a minimum I will update this disclosure annually;

" Where applicable, I will cooperate in the development of a conflict of interest "resolution plan."

" I will comply with any conditions or restrictions imposed by the Georgia Health Sciences University to

manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award.

 

Signature of Individual completing form:                                                                   Date: 

(Original signature only " a "per" signature is not acceptable.)

 

Signature of  Chair/Director or Dean:                                                                        Date: