Financial Conflict of Interest Disclosure

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Financial Conflict of Interest Disclosure Report

You must fill out a separate form for each company in which you have a financial interest and update each form annually or as changes occur.

This form is to be completed in connection with the Florida Gulf Coast University’s Policy on Financial Conflict of Interest in Sponsored Research, 2.018 by all key personnel who are involved in the review, design, analysis, conduct and/or reporting of research in which an entity of Florida Gulf Coast University is engaged. Answers should be completed based on the 12 months prior to form completion.

Should you have questions about the form, you may contact: Research@fgcu.edu.

Florida Gulf Coast University’s Office of Research & Graduate Studies will protect the confidentiality of private investments and personal finances and will request information related only to financial relationships that might influence the objectivity of research being conducted.

Your answer(s) to the questions do not imply that any financial interest you disclose is improper or impermissible. However, failure to report a financial interest or furnishing false, misleading or incomplete information may constitute professional misconduct and could be cause for disciplinary action.

Employee Information

Employee Name (printed)*

Prefix (optional)

First Name

Last Name

I participate in Public Health Service (PHS) or NSF funded research*

Yes No

Is the reported Financial Conflict of Interest related to a grant/contract/agreement for an externally sponsored project?*

Yes No

Project Title*

ORSP #

Not Required

I am disclosing financial interest for (entity name):*

In relation to the Entity above, please note the following section on Financially Interested Company: Significant Financial Interest: FGCU Policy Regarding Conflict of Interest requires that you report any compensation that you receive or Equity or Proprietary Interests that you have in an entity (i.e. the manufacturer of a product that is the subject of your Research project(s), its agent, or a company that is a direct and primary competitor to the manufacturer of the product) even if you purchased the Equity interest. The policy also requires that you disclose whether you hold a fiduciary position with an entity even if the position is unpaid.

1. Research or services performed for this entity generates personal income paid directly to a member of my immediate family or me.*

Yes No

Please explain why you responded Yes for item #1*

Please provide amount of income within the last year.* $

2. A member of my immediate family or I receive(s) personal income for consulting or other services from this entity.*

Yes No

Please explain why you responded Yes for item #2*

Please provide amount of income within the last year.* $

3. A member of my immediate family or I receive(s) personal income for other services (e.g. advisory services) for this entity.*

Yes No

Please explain why you responded Yes for item #3*

Please provide amount of income within the last year.* $

4. A member of my immediate family or I receive(s) personal royalties from this entity.*

Yes No

Please explain why you responded Yes for item #4*

Please provide amount of income within the last year.* $

Please provide amount of income within the last year. * $

5. A member of my immediate family or I has equity in this entity.*

Yes No

Please explain why you responded Yes for item #5*

This equity is *

$ amount % amount

Please provide the $ amount of equity held.* $

Please provide the % amount of equity held.*

6. Within the last 12 months, a member of my immediate family or I has been reimbursed by this entity for travel in connection with professional duties.*

Yes No

Please explain why you responded Yes for item #6*

Duration of Travel:*

To what location:*

Purpose of travel:*

Amount of reimbursement:* $

7. I receive compensation from or hold an Equity or Proprietary Interest in the disclosed entity.*

Yes No

Please explain why you responded Yes for item #7*

Will you receive any form of compensation from this entity?*

Yes No

Please explain the compensation you will receive from this entity.*

8. I hold a fiduciary position (Director or officer) in the disclosed entity.*

Yes No

Please explain why you responded Yes for item #8*

Once you submit this form, you may NOT go back to make changes. You can use the Save and Resume Later link below to make changes prior to submitting to the form.

Note: Attachments will only be saved upon final submission of the form.

Signature*

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Use your mouse or finger to draw your signature above

Date*

Email*

Confirmation of this submission will be sent to the email address above.

For ORSP use only:

ORSP #*

Received Date*

Notes:

Not Required