Financial Interests Disclosure Form

Disclosure forms are to be completed by all sponsor-funded Principal Investigators (PIs)/Project Directors (PDs) and their families that hold potential to directly and significantly affect the design, conduct or reporting of sponsored research/programs.

Significant Financial Interest (SFI) Descriptions:

Equity Interest – Non-publicly traded entity (e.g., stock, stock option, or other ownership interest)
Equity Interest – Publicly traded entity (e.g., stock, stock option, or other ownership interest)
Intellectual property rights (e.g., royalties, patents, copyrights) not from the awardee institution
Investment vehicles, such as mutual funds and retirement accounts, controlled by the investigator
Payment for services (e.g., consulting fees, honoraria, paid authorship)
Reimbursed or sponsored travel
Salary not from the awardee Institution
Advisory Board or Committee
Other (Provide an explanation that describes the SFI)*

Forms are to be completed:

1. Intitially, upon 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 or the St. Catherine University Financial Conflict of Interest Policy please contact the Sponsored Programs, Research & External Engagement (SPREE) office by email at spree@stkate.edu or by phone at 651-690-8811.

Exhibit A

Date of Disclosure * +

St. Kate's ID # *

First Name *

Last Name *

Email Address *

St. Kate's Phone Extension

School *

Department *

Disclosures

Reporting for: *

Self	Family Member

Family Member First Name *

Family Member Last Name *

Please select which SFI 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. *

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.