Investigator Financial Disclosure Form – Part I
Proposal Applications in COEUS

1.  Complete SECTIONS A and B and upload the document as a proposal attachment in COEUS.

2.  Submission of this form via COEUS represents your consent to the Investigator Certification.

3.  If any answer is checked ‘YES’ you will contacted for additional information.

4.  For any questions, contact Susan Gasparo at 2-9036 or

5.  Definitions and Information: http://research.stonybrook.edu/conflict-interest#overview-of-coi

SECTION A

CHECK THE APPROPRIATE BOX, YOU ARE:

1.  A Stony Brook Investigator
2.  A collaborator or consultant from another Institution that is receiving PHS funds via a subcontract from Stony Brook University’s Research Foundation
3.  A collaborator or consultant from another Institution that is receiving funds from a funding agency other than PHS via a subcontract from Stony Brook University’s Research Foundation. Disclosure under University Policy P209 is not required.
Date:
Full Name:
Institution if other than Stony Brook:
Department:
Stony Brook University PI if other than self:
Proposal Title:
COEUS Proposal # :
Role in the Activity:
SECTION B
Significant Obligations (SO)
Do you (or spouse or dependent children) hold any unpaid positions such as officer, trustee, director, employee, or consultant in one or more non-Stony Brook University, for-profit or not-for-profit entities?
YES NO
When answering the following sections, you do not need to disclose income from investment vehicles, such as mutual funds and retirement accounts, as long as you do not directly control the investment decisions made in these vehicles.
Publicly Traded Entities
Do you (and spouse or dependent children combined) have financial interest in any publicly traded entity where the value of any remuneration (any payment for services e.g., consulting fees, honoraria, paid authorship) received from the entity in the twelve months preceding this disclosure and/or the value of any equity interest (including stock, stock option, or other ownership interest, as determined through reference to public prices or other reasonable measures of fair market value) in the entity as of the date of disclosure, when added together, exceeds $5,000?
YES NO
Do you (and spouse or dependent children combined) employed by (a) vendor or supplier of goods or services to this institution; OR (b) an entity that sponsors research at this institution; OR (c) a sub-recipient of sponsored funds at this institution AND hold a position that has the authority to make significant business decisions on behalf of the company?
YES NO
Non-Publicly Traded Entities: Remuneration
Do you (and spouse or dependent children combined) have financial interest in any non-publicly traded entity where the value of any remuneration (any payment for services e.g., consulting fees, honoraria, paid authorship) received from the entity in the twelve months preceding the disclosure, when aggregated, exceeds $5,000?
YES NO
Do you (and spouse or dependent children combined) employed by (a) vendor or supplier of goods or services to this institution; OR (b) an entity that sponsors research at this institution; OR (c) a sub-recipient of sponsored funds at this institution AND hold a position that has the authority to make significant business decisions on behalf of the company?
YES NO
Non-Publicly Traded Entities: Equity Interest
Do you (or spouse or dependent children) hold any equity interest (e.g., stock, stock option, or other ownership interest) in any non-publicly traded entity?
YES NO
Intellectual Property Rights, Royalties etc.
In the past 12 months, have you, your spouse or dependent children received income from royalty and other forms of payments in excess of (when aggregated) $5,000 resulting from successful commercialization of intellectual property rights and interests (e.g., patents, copyrights) licensed to any commercial entity or from the Research Foundation of SBU?
YES NO
Travel (FOR PHS SUBMISSIONS ONLY):
Have you had the occurrence, over the past 12 months, of any reimbursed travel or sponsored travel for business travel whether for Stony Brook or any other entity (i.e., that which is paid on your behalf and not reimbursed to you) that cumulatively equals $5,000 or more?
YES NO
Excluded from this requirement is travel that is reimbursed or sponsored by federal, state or local government agency, a United States institution of higher education as defined at 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,
Check here if you answered yes to any of the questions above:
·  Are students, who are under your supervision, to be involved in this activity? __No ___Yes
·  Are animals, subject to IACUC approval, to be involved in this activity? ___No ___Yes: IACUC #_____
·  Are human subjects to be involved in this activity? ___No___Yes: CORIHS #_____
INVESTIGATOR CERTIFICATION

·  I have read and understood Stony Brook University’s Conflict of Interest Policy (P209)

·  I agree to file new or updated Investigator Disclosure Forms when the answers above change for any reason.

·  I certify that the answers to the declaration are accurate and truthful to the best of my knowledge.

Stony Brook University Page 1 of 3 Investigator Financial Disclosure Form - Part I
Office of Research Compliance (632-9036) September 4, 2015