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1. (a) During the past 12 months, did you, your spouse or your dependent children receive remuneration such as consulting fees, honoraria, speaker fees, advisory board fees from ANY publicly traded entity that when combined amounted to greater than $5,000 (U.S. dollars)? Because PHS regulations do not exclude income from authorship activities, you must include them in your response to this question. Please do not include equity, royalties or other payments on intellectual property rights in your response to this question.

Yes

No

*

1. (b) As of the date of this disclosure, do you, your spouse or your dependent children hold any equity interests in a publicly-traded entity? If so, does the value of this equity exceed $5,000 (U.S. dollars) either on its own OR when combined with any other remuneration from the same entity?

Yes

No

*

2. During the past 12 months, did you, your spouse or your dependent children receive any remuneration from ANY non-publicly traded entity that when combined amounted to greater than $5,000 U.S. dollars? Because PHS regulations do not exclude income from authorship activities, you must include them in your response to this question. Please do not include royalties or other payments on intellectual property rights in your response to this question.

Yes

No

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3. During the past 12 months, did you, your spouse or your dependent children hold ANY equity interests in any non-publicly traded entity?

Yes

No

*

4. During the past 12 months, did you, your spouse or your dependent children receive any remuneration from a non-profit entity that when combined amounted to greater than $5,000 U.S. dollars? Because PHS regulations do not exclude income for authorship activities or income from external professional organizations, you must include them in your response to this question. Also in accordance with PHS regulations, you must include income from a foreign institution of higher education or the government of another country in your response to this question. Do not include the following: • Income from seminars, lectures and teaching engagements sponsored by Indian or U.S. Federal, state or local government agencies; Indian or U.S. Institutions of higher education or Indian or U.S. research institutes; Indian or U.S. academic teaching hospitals or Indian or U.S. medical centers that are affiliated with Indian or U.S. Institutions of higher education; • Income from service on advisory committees or review panels for Indian or U.S. Federal, state or local government agencies; Indian or U.S. Institutions of higher education or Indian or U.S. research institutes; Indian or U.S. academic teaching hospitals and Indian or Indian or U.S. medical centers that are affiliated with Indian or U.S. Institutions of higher education; and • Royalties or other payments on intellectual property rights in your response to this question.

Yes

No

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5. During the past 12 months, did a third party pay for greater than $5,000 (U.S. dollars) of travel for you, your spouse or your dependent children related to your responsibilities at PHRII? For the purposes of this disclosure, travel costs are those that exceed $5,000 U.S. dollars (either for one trip or a combination of trips from a single entity). Travel costs include meals, transportation, lodging, and registration fees. Third party paid travel means: • Third party directly pays in whole or in part for travel on your behalf • You pay for travel and third party reimburses you in whole or in part • PHRII pays in whole or in part for travel and the third party reimburses PHRII PHS regulations include travel paid by: • For profit entities • Non profit entities including external processional organizations and societies • Academic journals and publishing companies; and • a foreign institution of higher education or the government of another country. PHS regulations exclude travel paid by: • Subrecipient Organization; • Indian or U.S. Federal, state or local government agencies; • Indian or U.S. Institutions of higher education or Indian or U.S. research institutes; and • Indian or U.S. academic teaching hospitals or Indian or Indian or U.S. medical centers that are affiliated with Indian or U.S. Institutions of higher education.

Yes

No

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6. During the past 12 months did you, your spouse, or your dependent children have any income greater than $5,000 for intellectual property rights (e.g., patents, patent applications, license agreements, or copyrights) resulting from or related to your work at PHRII? Do not include payments from or intellectual property owned by PHRII

Yes

No

Certification *

I certify that I have read and understand PHRII’s Financial Interest Disclosure Policy and have completed this Disclosure to the best of my knowledge and belief. Further, as someone who is identified as an investigator on a PHS proposal/award, subaward, or non-federal sponsor adopting the Public Health Services (PHS) regulations, I agree to comply with PHS regulatory requirements adopted as PHRII’s policy as well as acknowledge the following: • No later than at the time of proposal/application I will ensure that a current financial interest disclosure is on file. • I will fulfill my disclose responsibilities at least annually or within 30 days of discovering or acquiring (e.g., through purchase, marriage, or inheritance) a new SFI during the period of the award whichever comes first, including the occurrence of any reimbursed or sponsored travel which is paid on my behalf, related to my responsibilities at PHRII. • If I fail to report a new SFI within 30 days, I will willingly participate in the required retrospective review of my research in order to determine bias. • With the decisions of COIC Committee/designated official reflected in a management plan, if one is issued. • If I am a PI, I will appropriately identify individuals (i.e.,” investigators”) if any, in my proposal who are responsible for the conduct, design, or reporting of the research. I will take into consideration the role of the investigator, rather than their title and the degree of independence with which the investigator will work. • If I am a PI, I will complete my progress report in a timely fashion to assist the PHS Grantee in its reporting requirements related to any identified and previously reported FCOIs. • That PHRII must comply with written requests for information regarding my reported FCOIs. PHRII’s response must be within 5 business days and will include: 1) My name; 2) My title and role with respect to the research project; 3) The name of the entity in which the significant financial interest is held; 4) The nature of the significant financial interest; and 5) The approximate dollar value of the significant financial interest will be provided in the following dollar ranges: $0–$4,999; $5,000–$9,999; $5,000–$19,999; amounts between $20,000–$100,000 by increments of $20,000; amounts above $100,000 by increments of $50,000), or a statement that the interest is one whose value cannot be readily determined through reference to public prices or other reasonable measures of fair market value; and • That PHRII may impose sanctions on me if I fail to comply with the PHS regulations and PHRII policy. Signature:

First Name

Last Name

Date *

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DD

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