Conflict of Interest Investigator Financial Disclosure Statement

As an applicant to a federal granting agency, you will need to submit this form to the College’s Research Integrity Officer, who is the Provost, before your proposal can be submitted through the College. All investigators/senior personnel who are responsible for the design, conduct or reporting of the research or educational activities proposed for federal funding must provide this information, not just the PI. Please read the College policy on financial disclosure in Allegheny’s Faculty Handbook and indicate below whether or not you have any conflicts of interest. If you receive a federal award, you will need to complete this form annually for the duration of the grant.

We are collecting this information to comply with federal grant management requirements. It is not submitted with the proposal, and it remains confidential unless needed for resolving a conflict or if requested by a government agency.

_______________________

 

I hereby certify that I have read the Financial Disclosure Policy for All Investigators Conducting Research Funded by Federal Grants (“Financial Disclosure Policy”) in the Allegheny Faculty Handbook, which is effective for all federal proposals submitted through the College, and that the following information is true and correct:

1. Do you or any member of your immediate family (spouse, partner, or dependent children) have any Significant Financial Interests (SFI) in a Publicly-Traded Entity that might reasonably appear to be related to your Institutional Responsibilities as defined in the Financial Disclosure Policy?  (An SFI for publicly-traded entities exists if the value of any equity interest as of the date of disclosure combined with any remuneration in the past 12 months exceeds $5,000.)

____ No

____ Yes   Please attach a separate sheet with the name of the entity, nature of the interest(s), and monetary value of the interest(s).

2. Do you or any member of your immediate family (spouse, partner, or dependent children) have any Significant Financial Interests (SFI) in a Privately-Held Entity that might reasonably appear to be related to your Institutional Responsibilities as defined in the Financial Disclosure Policy?  (An SFI for privately-held entities exists if the value of any remuneration in the past 12 months exceeds $5,000, or when the Investigator or immediate family member holds any equity interest.)

____ No

____ Yes   Please attach a separate sheet with the name of the entity, nature of the interest(s), and monetary value of the interest(s).

3. Have you or any member of your immediate family (spouse, partner, or dependent children) received any income related to intellectual property rights and interests that might reasonably appear to be related to your Institutional Responsibilities as defined in the Financial Disclosure Policy?  (Do not include any intellectual property that has been assigned to Allegheny College.)

____ No

____ Yes   Please attach a separate sheet with the name of the entity from which income was received, nature and identity of the intellectual property rights or interests for which income was received, and amount of income received.

4. In the past 12 months have you undertaken any travel related to your Institutional Responsibilities as defined in the Financial Disclosure Policy that was either reimbursed or paid for by any individual or entity other than a federal, state, or local government agency, an institution of higher education, an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education.

____ No

____ Yes   Please attach a separate sheet with the purpose of the trip, name of the sponsor/organizer/individual who paid for your travel, destination, duration of the trip, and approximate monetary value of the travel.

To the best of my knowledge, I have made all required financial disclosures.  If any situations arise, of which I am aware, that are in any way contradictory to the above answers, I will immediately notify the College’s Research Integrity Officer and make full disclosure of any conflict, real or potential.

Name and Position:                                                                                                                

Title of Proposal:                                                                                                                    

Investigator Signature:                                                                        Date:                         

Allegheny Representative:                                                                  Date: