Conflict of Interest Disclosure for Subrecipients of WFBMC Research Funding

Confirm Understanding of the Policy

I have read and understand the research-related provisions of the WFBMC Policy on Conflict of Interest (Section III). Agree

What to Disclose

The following questions pertain to any outside entities with which you (or an immediate family member - related by blood, marriage or adoption) had a relationship during the previous calendar year (January - December) that could be perceived as a conflict of interest on this project. Outside entities include companies, service providers, non-government organizations (NGOs), foundations, and any other for-profit or not-for-profit entities (includes entities outside of the U.S.).

Income - Disclose any income earned from providing labor or services to an outside entity (includes but not limited to consulting, advisory boards, speaking, paid editorial services).

Equity holdings or ownership - Disclose any shares of equity owned, including stock options, warrants or promises of such, etc., whether the company is privately or publicly held and even if there is no current value. Ownership in mutual funds is excluded.

Intellectual property rights/License agreements - Disclose intellectual property rights owned, license agreements and/or royalties received, including those paid to you by WFBMC.

Fiduciary responsibility - Disclose fiduciary responsibilities with any outside entities (for-profit and not-for-profit), including but not limited to board memberships, company officer role or executive management role, whether paid or unpaid.

Question 1: Did you conduct speaking or consulting and/or have an income-producing relationship with any outside entity that is funding or supplying resources for this project? No Yes If Yes, name the entity and describe the activity Provide the income received Question 2: Did you or a member of your immediate family receive unrestricted support, an unrestricted grant, contract and/or gifts (either monetary, products or equipment) from an outside entity that is funding or supplying resources for this project? No Yes If Yes, name the entity and describe the relationship Provide the value and/or income received Question 3: Did you or a member of your immediate family have a paid or unpaid managerial, director, board member or company officer role with an outside entity that is funding or supplying resources for this project? No Yes If Yes, name the entity and describe the activity Question 4: Do you or a member of your immediate family own intellectual property rights or interests, have pending license agreements, or receive royalty payments for intellectual property being evaluated or utilized in this project? No Yes If Yes, describe the invention or technology If royalties were received, provide the income and name the licensing entity Question 5: Do you or a member of your immediate family own equity or have ownership in an outside entity that is funding or supplying resources for this project? No Yes If Yes, name the entity/entities and value of the equity or stock Question 6: In the previous 12 months, have you had any travel sponsored or reimbursed to you, regardless of the amount, by a for-profit or nonprofit entity related to this research project (excluding federal, state or local government, a U.S. institution of higher education, or an affiliated medical center, hospital or research institute)? No Yes If Yes, name the entity/entities who sponsored or reimbursed your travel: Question 7: If this application will receive any federal funding, do you have any appointments, positions (including volunteer, adjunct, honorary, etc.), or affiliations, with or without salary support, at a foreign entity relevant to this research? N/A No Yes If yes, name the foreign entity/entities and provide details about your appointment, position, or affiliation at the entity/entities: Question 8: If this application will receive any federal funding, do you receive any income, salary, consulting fees, or honoraria from a foreign entity in support of your other research endeavors? N/A No Yes If yes, name the foreign entity/entities and provide details about your compensation from the entity/entities: Question 9: If this application will receive any federal funding, has a foreign government or institution of higher education paid >$5,000 for your travel in the last year? N/A No Yes If yes, name the foreign entity and provide details about your compensation and travel related to the entity/entities:

Assurance and Certification

I hereby acknowledge that I have read and understand the research-related provisions of the WFBMC Policy on Conflict of Interest.

I affirm that the information I provided is to the best of my knowledge true and complete and does not misstate any facts.

I will provide any additional information as requested by the WFBMC Conflict of Interest Office.

I agree to cooperate in the development of any needed Management Plan as required per the Federal Regulations to manage, reduce or eliminate real or perceived conflicts of interest related to this research project.  I agree to comply with the terms and conditions contained in any Management Plan developed for this research project.

Check this box to confirm that you understand and agree with the above statements, and all your disclosures are up-to-date. After clicking the box, submit your form..