Significant Financial Interest Disclosure
   (Applicable to all PHS and NSF Sponsored
              Project Proposals)

Faculty/Staff Name___________________________

Department/Unit______________________________

Proposal Submitted To:

_____________________________________________

I am disclosing the following Significant
Financial Interests that may be affected by
the proposed research project and attach
supporting documentation (in an envelope
MARKED CONFIDENTIAL) that identifies the
nature and amount of the interest and the
business enterprise or entity involved:

("Significant Financial Interests" are
defined as interests, in the aggregate,
valued at greater than $10,000 in the next
twelve month period, or any single equity or
ownership interest of more than five percent
and valued at more than $10,000, held by an
Investigator and the Investigator's spouse or
dependent children.  See instructions for
exempt interests.)

     Check all that apply:

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

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

o    Intellectual property rights (e.g.,
     patents, copyrights, and royalties from
     such rights).

o    Other Significant Financial Interest of
     the Investigator that possibly could
     affect or be perceived to affect the
     results of the research or educational
     activities funded or proposed for
     funding.

Further I agree:

1.   To update this disclosure during the
     period of the award, on an annual basis,
     and as new reportable Significant
     Financial Interests are obtained.
2.   If necessary, to cooperate in the
     development of a Memorandum of
     Understanding (MOU) that constitutes a
     conflict of interest "resolution plan".
3.   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.


Signed: _____________________________________

Date: _______________________________________
      (original signature only) 

Endorsements:

I have reviewed the Significant Financial
Interest Disclosure and understand that
federal regulations require a determination
of whether or not the disclosed Significant
Financial Interests constitute a potential
conflict of interest that could directly and
significantly affect the design, conduct, or
reporting of the proposed project. If so,
prior to the any expenditure of funds an
acceptable conflict of interest resolution
plan will be developed to manage, reduce, or
eliminate any conflict of interest.  
I recommend that proposal be submitted to the
agency at this time.

Department / Unit Head:  

________________________________________    
                    Signed              

____________________
          Date


College Dean / Director: 

________________________________________    
                    Signed              

____________________
          Date

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