Request for Information regarding Financial Conflict of Interest related to PHS-Funded Research

Cornell University is committed to overseeing the conduct of research in a manner that ensures the integrity of the research process and maintains the public trust and that of sponsors in the integrity and credibility of its faculty, its staff, and its research programs. Cornell’s policy 1.7, Financial Conflict of Interest Related to Research describes the University’s commitment and procedures related to the identification and management of real or apparent conflicts of interest that arise from the intersection of personal financial interestsandresearch activities. Additional information about Cornell’s procedures, policies, FAQs, can be found on the COI website at

To comply with the Public Health Service (PHS) regulations on Responsibility of Applicants for Promoting Objectivity in Research for which PHS Funding is Sought [(42 C.F.R. Part 50, Subpart F) and Responsible Prospective Contractors (45 C.F.R. Part 94)], Cornell University will make available within 5 business days upon receipt of a request as described below, of information concerning Significant Financial Interest (SFI) disclosed to Cornell that meets the following criteria:

  • The individual for whom information is sought, is identified by Cornell in the grant application, progress report, or any other required report submitted to the NIH as a senior/key personnel on an NIH grant or cooperative agreement for which a notice of award was issued on or after August 24, 2012;
  • The SFI is still held by the senior/key personnel for the NIH-funded research project;
  • Cornell has determined that the SFI is related to the NIH-funded research; and
  • Cornell has determined that the SFI is a Financial Conflict of Interest.

If your request meets the conditions outlined above, please follow the instructions below:

Instructions:

  1. Complete this form for each SFI for which you are seeking information. Incomplete forms will not be considered and will not be responded to.
  2. Print, sign and attach a scanned copy to an email. The title of the email should be: “Public request for information regarding NAME OF INVESTIGATOR on NIH AWARD #”. Send the email with attachment to
  3. Alternatively you can print the completed form, sign and send it by regular mail to:
    Director

Office of Research Integrity and Assurance,

395 Pine Tree Road, Suite 320,

Cornell University

Ithaca, NY 14850

  1. Cornell University will respond via email to the email address provided in the form. If a paper copy is required, please enclose a self- addressed, postage paid envelope. Mailed responses will be postmarked no later than five (5) days after receiving a valid request (as described above) at the email address or the mailing address provided above.

Request for Information regarding Financial Conflict of Interest related to PHS-Funded Research

  1. Information about you:

Name (first, last):

Email address:

Street address:

City, State, Zip code:

  1. Information about your request:

PHS award number

(Format 5R21AB123456-01)

PHS Award title

Investigator Name

Please state the reason for requesting this information:

YourSignature : ______

Date: ______

Please complete, sign, scan and email this form to or mail it to ORIA, 395 Pine Tree Road, Suite 320, Cornell University, Ithaca, NY 14850

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