Financial Interest Disclosure Form

Instructions: Principal Investigators are responsible for ensuring that this form is completed for each member of the research staff reporting a financial interest related to the research. For more information about Harvard conflict of interest policy, visit:

A. PROTOCOL INFORMATION
Protocol Number:
Protocol Title:
Principal Investigator or Faculty Advisor / Degree(s): / /
B. RESEARCH STAFF WITH FINANCIAL INTEREST.
Name (first, last degree): / ,
Do you or your Immediate Family[i] have any ownership interest Related to the Research[ii] of any value including, but not limited to stocks and options, exclusive of interests in publicly-traded, diversified mutual funds. / Yes No
Do you or your Immediate Family have any compensation Related to the Research of any amount including, but not limited to honoraria, consultant fees, royalties, or other income. / Yes No
Do you or your Immediate Family have any proprietary interest Related to the Research of any value including, but not limited to patents, trademarks, copyrights, and licensing agreements. / Yes No
Do you or your Immediate Family have any board or executive relationship, Related to the Research regardless of compensation. For more information, contact the office of technology department at . / Yes No
Do you or your Immediate Family have any reimbursed or sponsored travel Related to the Research of any amount by an entity other than a federal, state, or local government agency, higher education institution or affiliated research institute, academic teaching hospital, or medical center. / Yes No
C. DESCRIPTION AND MANAGEMENT OF FINANCIAL INTERESTS
Describe the financial interest(s) (include the dollar value/amount if applicable; indicate whether any arrangements have been entered into whereby the value of the interest would be affected by the outcome of the research):
If you have a proposed or established plan to manage the financial interest, describe it here:

Financial Interest Disclosure Form | HRP-221 | Version date: January 18, 2017 | Page 1 of 1

University Area IRB

Longwood Medical Area IRB

[i]Immediate Family means spouse, domestic partner, and dependent children.

[ii]Related to the Researchmeans any interest in the sponsor, product or service being tested, or competitor of the sponsor held by the individual or the individual’s Immediate Family.