CONFLICT OF INTEREST DISCLOSURE STATEMENT

Type of Reporting Initial disclosure Change in disclosure

IRB-Spokane recognizes the essential relationships between investigators, key research personnel and manufactures of drugs, medical devices and biotechnology agents. However, these relationships may give rise to conflicts of interest, which may interfere, or give the appearance of interfering, with the protection of human subjects and/or the integrity of the research project. Please see page 3 for additional information.

All key research personnel (listed on IRB application) must complete and submit this disclosure statement. Completed forms will be reviewed by a Providence Conflict of Interest Committee and/or by the IRB. Review of disclosed conflicts of interest areanalyzed for the potential effect on the conduct of the study as well as whether appropriate human subject protection safeguards may be necessary to manage the conflicts of interest.

If disclosures on this form are not clear, the review process for proposed research will be delayed. Additionally, please note that you are required to report and update conflicts of interest as soon as a change occurs.

Study Title:

Protocol Number (if applicable):

PI Name:

IRB Number if change in disclosure:

Name of Key Research Personnel:

What is your role in this study (ex: PI, SI, coordinator):

Check all boxes that apply.

NONE

Speaking fees or honoraria during the last 365 days:

Total Payment: $

Consulting fees during the last 365 days:

Total Payment: $

Equity interest in Sponsor (e.g., stock options, etc. – do not include diversified mutual funds or similar instruments in whichShareholders have no control over the equities held in the fund):

Publicly Traded -- Number of Shares: -- Value: $

Not Publicly Traded -- Number of Shares: -- Value:$

Intellectual Property Rights including patent, copyright, trademark interests, licensing agreements involving a study-relatedproduct, receipt of royalty payments:

Value:$

Identify the nature of intellectual property interest:

Fiduciary role with Sponsor (e.g., corporate officer, director):

Identify role:

Other relationship with Sponsor (e.g., employed spouse):

Identify relationship:

Other payment or remuneration arrangement associated with the research (e.g., recruitment bonuses), (excluding clinical trialagreement):

Value: $

Identify nature:

Other potential conflict of interest:

Please describe in detail:

I confirm that the information in this disclosure statement is true and accurate to the best of my knowledge.

Printed/Typed Name:

Signature: ______Date: ______

Definitions –

Conflict of interest – a conflict of interest exists when investigator or key research personnel’s financial, personal or professional interests would potentially or actually compromise the person’s professional judgment in conducting or reporting research. A conflict of interest also exists when it may be perceived as compromising the person’s professional judgment in conducting or reporting research. Financial, personal or professional interests include those of the research personnel and those of their immediate family.

Significant financial interest – The following are examples and not intended to be anall-inclusive list:

  • Consulting Fees
  • Honoraria
  • Gifts or other payments, rewards or fees
  • Compensation from company, whether for:
  • Consulting
  • Lecturing
  • Travel
  • Service on an advisory board
  • Any other purpose not directly related to the reasonable costs of conducting the research (as specified in the research agreement), that total in excess of $5,000 in the prior calendar year
  • Equity interests in a publicly-traded financially interested company that exceed $5,000 or that represent more than a 5% ownership interest in a single entity
  • Any direct equity interests, including stock options, that exceed $5,000 in a non-publicly-traded financially interested company
  • Intellectual property rights (e.g. patents, copyrights) and/or royalty income or the right to receive future royalties under a patent, license, or copyright, where the research is directly related to the licensed technology or work
  • Any non-royalty payments or entitlements to payments in connection with the research that are not directly related to the reasonable costs of the research (including any bonuses or milestone payments in excess of reasonable costs incurred, whether received from the financially interested company or the institution)
  • Service as an officer, director or any other fiduciary role for a financially interested company, whether or not remuneration is received for such service.

Significant financial interest does not include – any interests held solely by reason of investment in a business by mutual, pension or other institutional investment fund over which the research personnel or immediate family members do not exercise day-to-day control of investment decisions.

Research personnel – Investigators, co- or sub-investigators, study coordinators or any other personnel involved in the design, conduct or reporting of the research project.

Immediate family – Spouse or domestic partner, minor children, adult children and their spouses or domestic partners, siblings and their spouses or domestic partners, and parents of the investigator. These individuals will be considered immediate family members if the family member resides in the same household as the investigator or if the investigator has actual knowledge of the immediate family members’ financial interest.

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