Conflict Disclosure Form for Subcontractors, Consultants, and Collaborators

Last Name *

First Name *

E-mail Address: *

Employer Name (Please enter "Self" if you are a consultant on a project) *

Reason for Disclosure: *

Enter Subaward ID Number: *

Enter IRB Protocol Number and Project Title: *

Enter Reference Number or Project Title: *

Disclosure Type:

Initial Disclosure

Annual Disclosure

Addendum to Most Recent Report

Designated Campus Colleague Pre-Review

Please enter the date on which you completed the required University of Arizona conflict of interest training. By entering a date, you are certifying that you completed the required training. If you have not completed the required conflict of interest training, please do not complete this form until after you have done so. For instructions on how to complete the training, please contact the University of Arizona's Office for Responsible Outside Interests at (520) 626-6406 or coi@arizona.edu.

Training Completion Date *

Month

Day

Year

1. Travel

Is the prime sponsor on your subaward from the University of Arizona any of the entities listed below? The prime sponsor is the sponsor on the award to the University of Arizona, which results in the subaward to your institution. Contact your subaward team member at if you are unsure.

Agencies Using the PHS FCOI Regulations *

If you responded "Other" above, provide the name of the project's Prime Sponsor.

Other Prime Sponsor for Travel

2. Remuneration

(Complete a separate disclosure for each entity)

Have you or a family member received Remuneration in the past twelve (12) months from any publicly traded or privately held entities other than the employer listed above? *

Yes

No

3. Ownership Interests

(Complete a separate disclosure for each entity)

Do you or any of your Family Members own any stock or other ownership interest, or an entitlement to obtain any stock or ownership interests (e.g., stock options and warrants) in a publicly-traded or privately-owned entity? *

Yes

No

4. Intellectual Property

(Complete a separate disclosure for each entity)

Do you or any of your Family Members have rights to or receive royalties from intellectual property (including patents, copyrights, and trademarks)? *

Yes

No

5. Role

(Complete a separate disclosure for each entity)

Do you or any of your Family Members hold any managerial, professional, or fiduciary positions (e.g., officer, director, trustee, advisory board member, board of directors, or other managerial position) in an entity other than the employer named above. *

Yes

No

6. If you answered "Yes" to any of questions 1-5, above, please complete the following items. If you answered "No" to questions 1-5, above, scroll to item 7 at the bottom of this form and submit your disclosure.

What is your role in the UA research that has relatedness to your financial interest?

PD/PI

Co-PD/PI

Senior/Key Personnel

Other. Please describe below.

Other Role Explanation

If you responded "Other", above, please provide a short description of your role.

Provide a detailed description of the research and your activities on the research project:

Does the research to be conducted in this subcontract involve the testing of any drugs, devices, assays, biologics, software, equipment, products, procedures, materials or other technology belonging to, or with significant potential impact on, your significant financial interest?

Yes

No

Testing of Drugs response

If yes, please list the drugs, devices, assays, biologics, software, equipment, products, or technologies:

Is this human subjects research? *

Yes

No

If yes, has this project been approved by UA's IRB?

Yes

No

Are you involved in the recruitment, selection, referral, care, and/or consenting of the human subjects participating in the study?

Yes

No

If yes, indicate which of these activities you perform:

Is this clinical research? *

Yes

No

If yes, what phase clinical trial?

Is it a multi-site clinical trial?

Yes

No

Please list your Other Support here: *

Other Support refers to: all resources made available, or expected to be made available, to an individual in support of the individual's research and development efforts, regardless of (1) whether the source is foreign or domestic; (2) whether the resource is made available through the entity applying for a research and development award or directly to the individual; or (3) whether the resource has monetary value; and includes in-kind contributions requiring a commitment of time and directly supporting the individual's research and development efforts, such as the provision of office or laboratory space, equipment, supplies, employees, or students. This term has the same meaning as the term Other Support as applied to researchers in NSPM-33. For researchers, Other Support includes all resources made available to a researcher in support of and/or related to all of their professional R&D efforts, including resources provided directly to the individual rather than through the research organization, and regardless of whether or not they have monetary value (e.g., even if the support received is only in-kind, such as office/laboratory space, equipment, supplies, or employees). This includes resource and/or financial support from all foreign and domestic entities, including but not limited to, financial support for laboratory personnel, and participation of student and visiting researchers supported by other sources of funding.

Do you have any of the following Foreign Affiliations? *

7. Certification

I certify that:

I have completed the University of Arizona's conflict of interest training;
I understand the University of Arizona's conflict of interest disclosure requirements, including annual certification requirements;
I have used all reasonable diligence in preparing this statement and that it is true and correct;
I will comply with any conditions or restrictions imposed by the University of Arizona to manage any Financial Conflicts of Interest; and
Should my outside financial or personal interests, or those of my Family Members, change in a way that results in a different answer to any of the questions asked in this report, I agree to submit a revision.

Conflict Disclosure Form for Subcontractors, Consultants, and Collaborators

1. Travel

2. Remuneration

3. Ownership Interests

4. Intellectual Property

5. Role

6. If you answered "Yes" to any of questions 1-5, above, please complete the following items. If you answered "No" to questions 1-5, above, scroll to item 7 at the bottom of this form and submit your disclosure.

7. Certification

Support for Researchers

Resources

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Conflict Disclosure Form for Subcontractors, Consultants, and Collaborators

1. Travel

2. Remuneration

3. Ownership Interests

4. Intellectual Property

5. Role

6. If you answered "Yes" to any of questions 1-5, above, please complete the following items. If you answered "No" to questions 1-5, above, scroll to item 7 at the bottom of this form and submit your disclosure.

7. Certification

Support for Researchers

Resources