Financial Conflict of Interest Disclosure
This statement should be completed prior to proposal submission or at time of award and given to the Grants Office.
Name: ______Department: ______
Project Role:
ð Lead Principal Investigator/Project Director/Coordinator
ð Other Senior/Key Personnel with significant project responsibility
Project Title: ______
Funding Agency: ______
By signing below, I certify that:1. The attached proposal is complete in its technical content, adheres to the rules of proper scholarship including proper attribution and citation of all text and graphics, and meets the specifications outlined by the sponsoring agency.
2. If the attached proposal is awarded and accepted by Cape Cod Community College, I will conduct the project according to the terms and conditions of the funding agency and the policies of Cape Cod Community College, and meet the requirements of the award including stewardship of funds and submission of all required project or technical reports.
3. If the proposed activity involves the use of human subjects, human materials, vertebrate animals, biohazards, or radioactive materials, I understand it will be necessary to obtain appropriate review and approval prior to beginning the project.
4. Check one of the following:
o I do not have any significant or other financial interests related to this project.
o I am disclosing the following significant financial interests (check all that apply) and attaching supporting documentation (in an envelope marked “Confidential”) that identifies the business enterprise or entity involved and the nature and amount of interest. Significant financial interests are defined as interests of greater value than $10,000 or an equity ownership of more than 5% held by an investigator or the investigator’s spouse or dependent children.
o Salary or other payment for services (consulting fee or honoraria)
o Equity interests (stocks, stock options, or other ownership interests)
o Intellectual property rights (patents, copyrights, and royalties from such rights)
o Other significant financial interests of the investigator that possibly could affect or be perceived to affect the results of the research or educational activities funded or proposed for funding.
Further, I agree:
§ To update this disclosure during the term of the award on an annual basis, or as new reportable interests are obtained.
§ To cooperate in the development of a conflict of interest resolution plan, should one be needed.
§ To comply with any conditions or restrictions imposed by the Cape Cod Community College to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award.
Signature: Date:
If there is Disclosure of Significant Financial Interests:
I have reviewed the significant financial interest disclosure and believe that it will be possible to manage, reduce, or eliminate any actual or potential conflict of interest; therefore, I recommend that the proposal be submitted to the agency at this time.
Controller’s Signature: ______Date: ______