PHS Significant Financial Interest (SFI) Disclosure Form

PHS Significant Financial Interest (SFI) Disclosure Form

(For PHS Applications & Grants ONLY)

Proposal Title:

Funding opportunity No. and/or name:

Grant PI:

Proposal Deadline:

Submission Time Points

ð  Prior to submitting PHS applications

ð  Within 30 days of a new SFI (e.g., through purchase, marriage, or inheritance)

ð  Within 30 days of travel that meets criteria in IV.

ð  Annually following a PHS award (i.e., any SFI not disclosed initially or in a subsequent SFI disclosure)

SUBMIT COMPLETED FORM TO DR. TOM LOMBARDO VIA EMAIL AT

Excluded PHS Applications: Phase I SBIR/STTR

PHS SFIs That Must be Disclosed

1.  Interests that reasonably appear to be related to teaching, research, administrative, or clinical duties

-AND-

2.  Received during the past 12 months

Excluded Financial Interests

1. Salary, royalties, or other remuneration paid by UM to you if you are currently employed or otherwise appointed by UM
2. Intellectual property rights assigned to UM and agreements to share in royalties related to such rights
3. 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
4. Income from seminars, lectures, or teaching engagements sponsored by a U.S. federal, state, or local government agency, an Institution of higher education as defined in 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
5. Income from service on advisory committees or review panels for a U.S. federal, state, or local government agency, or an 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

Interests held individually by the Investigator, his/her spouse, and dependent children must be added together and the aggregate value used to determine limits listed below

I.  With regard to any publicly traded entity:

The value of any remuneration and the value of any equity interest in the entity, when aggregated, exceed $5,000.

(Remuneration includes salary and any payment for services not otherwise identified as salary (e.g., consulting fees, honoraria, paid authorship)

(Equity interest includes any stock, stock option, or other ownership interest, as determined through reference to public prices or other reasonable measures of fair market value)

List values, type(s) of interest(s), and name and details of the publicly traded entity/entities here:

I DO NOT HAVE THIS SFI

II.  With regard to any non-publicly traded entity:

The value of any remuneration received from the entity, when aggregated, exceeds $5,000

OR

When you (or your spouse or dependent children) hold any equity interest (e.g., stock, stock option, or other ownership interest)

List values, type(s) of interest(s), and name and details of the non-publicly traded entity/entities here:

I DO NOT HAVE THIS SFI

III.  Any intellectual property rights and interests (e.g., patents, copyrights not assigned to UM), upon receipt of income related to such rights and interests.

List values, type(s) of IP rights & interest(s), and name and details of the non-publicly traded entity/entities here:

I DO NOT HAVE THIS SFI

IV.  Any reimbursed or sponsored travel (i.e., travel paid for on your behalf, but not reimbursed by UM & related to your UM research, administrative, clinical, or teaching duties)

Excluded is travel that is reimbursed or sponsored by the following:

o  A US Federal, state, or local government agency

o  A US Institution of higher education, academic teaching hospital, medical center

o  A research institute affiliated with a US Institution of a higher education

For each trip, list:

·  purpose of the trip

·  identity of the sponsor/organizer

·  destination

·  duration

·  monetary value

here:

I DO NOT HAVE REPORTABLE TRAVEL

______

If you Identified SFIs or travel above, the following must occur prior to award expenditure:

1.  This form (submit to Dr. Tom Lombardo via email at ) will be reviewed by ORSP COI staff to determine if a conflict of interest exists. They may consult with you on this determination. If a COI is evident, a conflict of interest committee will work with you to manage or eliminate the conflict.

2.  A conflict management/elimination process must be agreed to in a written memorandum of understanding.

3.  You must complete online training in conflict of interest ethics.

I certify that:
·  The above information is true to the best of my knowledge. I will notify ORSP of any change of status.
·  I will submit an updated Significant Financial Interest Disclosure to the ORSP within 30 days of any new significant financial interests or any travel that meets criteria in IV. during the award period.
Signature / Printed Name / Date

Confidentiality Information: These and all related conflict of interest records will be kept confidential and made available only on a need-to-know basis (i.e., to the Director of Research Integrity and Compliance, the Director of Technology Management, and the Conflict of Interest Committee members appointed by the Vice Chancellor of Research and Sponsored Programs). Records will be kept for 3 years after the date of submission of the final expenditure report, as required by federal regulation (42 CFR Part 50 Subpart F ).