CU IRB
Revised January 2016 / 1

CU IRB Conflicts of Interest(COI) Form

Researcher (PI or other

key researcher)

/ Last, First /

Date submitting this

COI form

/ mm/dd/yyyy

Researcher email

/

Department

PI if researcher is not PI

/

PI email

Study Title

Faculty Advisor and

otherKey Investigators

/ Last, First; Last, First;Last, First; list anyone involved in supervising the project or collecting data.

Sponsor Information

(if known)

/ Check one: ☐Not seeking funding ☐Seeking funding (but not funded yet) ☐FUNDED
Sponsor name: ______Funding dates: begin______end______

Proposed Research

Start Date

/ mm/dd/yyyy

Do you have any apparent Conflicts of Interest in this research?A conflict of Interest is not just when financial interests are involved, but rather any circumstance that could result in perception of undue influence or coercion. Please check “yes” or “no” to the following situations, which are examples of possible conflicts. Enter “other” if there is another potential conflict of interest. After completion, please email to the CU IRB Director, using the email address . Your report will be treated with discretion and respect.

If you check “YES” to any of the questions, feel free to write more detail or a description of what you might do to manage any possible apparent conflict (you can type this description and your suggested management plan here). Or, if you rather, you can simply turn in this form and we can discuss a management plan strategy together as described on our IRB website.

A researcher or family member participating in research on a technology, process or product owned by a business in which the researcher holds a financial interest. / Yes
☐ / No
☐
A researcher participating in research on a technology, process or product, where there is a potential for a financial gain, patentable invention or trademark. / Yes
☐ / No
☐
A researcher or family member assuming an executive position in a business engaged in commercial or research activities related to the researcher’s University responsibilities. / Yes
☐ / No
☐
A researcher or family member serving on the Board of Directors of a business from which that member receives University-supported Sponsored Research Support. / Yes
☐ / No
☐
A researcher receiving $10,000 or more in consulting income from a business or relationship that funds or supports his or her research. / Yes
☐ / No
☐
A researcher with a board or executive relationship related to the research, regardless of compensation. / Yes
☐ / No
☐
A researcher who wishes to recruit a subject who is a student, an employee, or a subordinate of the researcherwhen there is a grade, incentive, or even mere appearance of the researcher having some authority which might coerce (convince) participation. / Yes
☐ / No
☐
OTHER: If so, please describe below: / Yes
☐ / No
☐

Signature of Researcher: ______Date: ______

Print Name of Researcher: ______

Role on Project: ______

CU IRB Conflicts of Interest Form 2016 18aug16.docx