Conflict of Interest (COI) Management Plan

Conflict of Interest (COI) Management Plan

Declaration and Acknowledgment Form

This form provides information to current and future Researchers (staff, students, trainees, visiting scientists, etc.) of the relationship that exists between [Employee Name](the Employee) and the following entity:[Name of Entity](the Entity). [Include the following information about the Entity: The location, type of business (principal focus), the Employee’s relationship with Entity, including, as applicable, any positions held, board responsibility, and/or financial interest in Entity. Also include the Entity’s relationship with the University (e.g. The Entity was awarded a Phase I STTR award and will sub-contract approximately [x%] of the work to the University. The Employee will serve as the PI for the sub-contract awarded to the University).

[Employee’s Name] has filed a Conflict of Interest (COI) Disclosure with NCSU regarding his/her relationship(s) with the Entity, and a Management Plan in place.

The outcomes of this study, the work performed, study plan, or progress towards a degree of any of the Researchers must not be influenced by this relationship in any way. You have the right to accept or decline work related to this project. If you decide to participate in work related to this project:

1) Youwill conduct work on behalf of the University and not the Entity;

2) You will report to and take direction from your supervisor and not the Entity; and

3) You have the right to have confidential access to the Dean, his designee, or the [Name of Department] Head to discuss any conflict of interest issues, including but not limited to,the Employee’srelationship with the Entityon your work, advancement, studies, or progress towards a degree.

Their contact information is:

Dr. [Name of Dean]

Dean of College of [College Name]

(919) [Phone Number]

Email:[Email address]

Dr. [Name of Dept. Head]Dr. [Name of Assoc. Res. Dean]

Department Head,[Dept. NameAssociate Dean for Research, [College]

919-[Phone Number]919-[Phone Number]

Email: [Email address]Email: [Email address]

I acknowledge reading this form,which outlines the significant financial interest held by [Employee’s Name] and includes my right to bring any concerns regarding his/herrelationship with the Entityto the individuals named on this form.

Signed:______Date:______

Printed Name: ______

Received by Department Chair: ______Date: ______

[Name of Employee]Declaration & Acknowledgment Form

[Month Year]Page 1 of 1