VCOM Institutional Policy and Procedure Manual

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

Instructions

Under this Policy, Investigator is defined as the principal investigator and all others who have responsibility for the design, conduct or reporting of research (including data collection and data analysis). A financially interested company is an entity with financial interests that would reasonab ly appear to be affected by the outcome or conduct of the research. Please type your answers in the designated fields below, save and print out the disclosure form. Once you have signed, please submit the completed form to the principal investigator. Th e principal investigator is responsible for submitting all disclosure forms to the Office of Research Administration along with the application.

To learn more about disclosure requirements and what constitutes a potential conflict of interest, please se e the VCOM Financial Conflicts of Interest in Research Policy .

This form is not required for research that has no external funding or no financially interested company.

If you chec ked “Yes” to any of the questions, you must provide additional information regarding the entity involved and the nature and amount of the interest for the applicable 12 - month period via the Supplemental Research FCOI Disclosure Form found at: http://www.vcom.edu/ora/forms.html . The S upplemental Research FCOI Disclosure Form must be included with the grant application, along with this form. Failure to include the Supplemental form when reporting a financial interest on this form may result in delays in the review and submission process of the grant application.

Office of Research Administration

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Form Revised: 3.11.15