VCOM Institutional Policy and Procedure Manual

RESEARCH FINANCIAL CONFLICT OF INTEREST DISCLOSURE FORM Edward Via College of Osteopathic Medicine

In accordance with VCOM’s Financial Conflicts of Interest in Research Policy , all Investigators must disclose financial interests in an external entity that provides funding or support for the research project or that has an interest in the results of the research. This form must be submitted, even if the individual has no financial interests to disclose. Please see Instructions on the following page.

Full Name:

Division:

Title of Research Project: Funding/Support Source:

Research-Specific Disclosures

Within the past 12 months or for the next 12 months, have or will you, your spouse, your domestic partner or your dependent children or any foundation or entity controlled by you or your spouse:

NO 1. Receive consulting fees, royalty, honoraria, gifts or other payments or in kind compensation from an external entity that may appear to affect or be affected by the conduct or outcome of the study, for consulting, lecturing, service on an advisory board or for any other purpose not directly related to the costs of conducting research? NO 2. Receive any reimbursement for travel , or have travel paid for, by an entity that may appear to affect or be affected by the conduct or outcome of the study? (This does not include travel paid by government agencies, teaching hospitals, medical centers or institutions of higher education.)

YES

YES

3. Hold any outside position

(officer, director, trustee, consultant, employee, etc.) with an entity

YES

NO

that may appear to affect or be affected by the conduct or outcome of the study?

NO 4. Have ownership interests of any nature, including equity, stock options, etc., in an external entity that may appear to affect or be affected by the conduct or outcome of the study?

YES

NO 5. Have an intellectual property interest in a patent, patent application or copyright assigned or licensed (including those assigned to VCOM) to an external entity that may appear to affect or be affected by the conduct or outcome of the study?

YES

If you answer “Yes” to any of the above questions, you must provide additional information by completing the Supplemental Research FCOI Disclosure Form .

Acknowledgement and Certification I hereby certify that the above information is complete and true to the best of my knowledge, and that I have read and understand the VCOM Financial Conflicts of Interest in Research Policy , and agree to comply with such Policy. I acknowledge that I am responsible for submitting an updated Research Financial Conflict of Interest Disclosure Form, within 30 days, prior to any change in my financial or other interests that may appear to affect or be affected by this study. Date: All research personnel who have a responsibility for the design, conduct or reporting of research must complete this form. Please see instructions on following page. If you have questions, please contact the Office of Research Administration. Signature:

Office of Research Administration

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Form Revised: 3.11.15