Financial Conflicts of Interest and Conflicts of Commitment Disclosure Form

There are two primary types of disclosures, Financial Conflicts of Interest (FCOI) and non-financial Conflicts of Commitment (COC). As an applicant for and/or recipient of certain federal or state research funds, you are required to complete disclosures related to each using this form.

Conflict of Commitment (COC) means a non-financial conflict of interest in which an individual accepts or incurs conflicting obligations, whether domestic or foreign, between or among multiple employers or other entities. COC includes conflicting commitments of time and effort, including obligations to dedicate time in excess of institutional or funding agency policies or commitments. COC also includes obligations to improperly share information with, or to withhold information from, an employer or sponsoring agency, as well as other conflicting obligations that threaten research security and integrity.

Financial Conflict of Interest (FCOI) means a significant financial interest that has potential to directly affect the design, conduct or reporting of sponsored research. It refers to anything of monetary value, including, but not limited to, salary or other payments for services (e.g., consulting fees or honoraria); equity interest (e.g., stocks, stock options or other ownership interests); and intellectual property rights (e.g., patents, copyrights and royalties from such rights).

The term does not include:

salary, royalties or other remuneration from the applicant organization;
income from seminars, lectures, or teaching engagements sponsored by public or non-profit entities;
income from service on advisory committees or review panels for public or nonprofit entities;
an equity interest that, when aggregated for the investigator and the investigator’s spouse and dependent children, meets both of the following tests: does not exceed $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and does not represent more than a 5% ownership interest in any single entity; or
salary, royalties or other payments that, when aggregated for the investigator and the investigator’s spouse and dependent children, are not expected to exceed $10,000 during the prior twelve-month period.

Forms are to be completed:

1. Intitially, prior to submission of a sponsored program proposal.

2. Thereafter, disclosure forms must be updated:

a. Within 30 days of discovering or acquring a new significant financial interest.

b. Annually in the period of an award, beginning with the anniversary date of the original disclosure.

If you have any questions about this form please contact the Sponsored Programs, Research & External Engagement (SPREE) office by email at spree@stkate.edu

Exhibit A

Date of Disclosure * +

St. Kate's ID # *

Grant Project *

Funder *

First Name *

Last Name *

Email Address *

St. Kate's Phone Extension

School *

Department *

Financial Conflict of Interest Disclosure

Reporting for: *

Self	Family Member

Family Member First Name *

Family Member Last Name *

Please select which COI you currently have (see descriptions above): *

Compensation (including travel expenses):

In the last two (2) years, have you or a member of your family received compensation from an entity for activities such as consulting, expert witness, advisory board membership, and the like? *

Yes

No

Compensation: Please provide further detail. *

Equity:

Do you, or a member of your family, own stock/hold stock options with a publicly-traded company or own part of a privately-owned entitity? *

Yes

No

Equity: Please provide further detail. *

Role:

Do you or a member of your family serve as a director, trustee, officer or other key employee in a for-profit entitity, partnership, business, or other entitity outside of St. Catherine University? (Including non-paid board positions.) *

Yes

No

Role: Please provide further detail. *

Intellectual Property:

Do you or a member of your family have rights to and/or receive royalties from intellectual property (including patents, copyrights, and trademarks but excluding academic or scholarly works) licensed to and/or owned by a for-profit entity? Do NOT include intellectual property owned or managed by St. Catherine University. *

Yes

No

Intellectual Property: Please provide further detail. *

Conflict of Commitment Disclosure

Conflict of Commitment: Do you have a conflicting obligation between or among multiple entities or employers (including but not limited to current or pending employment, appointments, positions, or affiliations where salary or honoraria are received)? *

Yes

No

Conflict of Commitment. Please provide further detail: *

Certification

By submitting this form, you certify:

I have read and understand the St. Catherine University Financial Conflict of Interest Policy and have completed this report to the best of my knowledge and belief. If required, I will comply with any conditions or restrictions imposed by St. Catherine University to manage any real or perceived conflicts. Should my financial or managerial interests, or those of my family, change in a way that results in different answers to any of the questions asked in this report, I agree to submit a revised form within 30 days of said change.