Disclosure Form for nsf conflict of Interest Policy (Form 900) Financial Interests Related to Sponsored Projects- please type your responses




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Disclosure Form for NSF Conflict of Interest Policy (Form 900)

Financial Interests Related to Sponsored Projects- Please type your responses

Completion of this form is mandatory for all Investigators on proposals to the National Science Foundation (NSF), or other sponsors that follow the NSF requirements for financial disclosure. This information is required to comply with the University of California “Disclosure of Financial Interests and Management of Conflicts of Interest, National Science Foundation Awards” and NSF policy on Conflict of Interest.




Principal Investigator:  

Email:  

Project Begin Date:  

Project End Date:  

Project Title:  

UCI’s Sponsor:

 NSF


 Subcontract of NSF funds from  

 California Institute Regenerative Medicine (CIRM)

 UC Discovery Grants

 UC Special Research Programs

 Other  


This submission is for (check one):

 New Proposal

 Change in Financial Interest




Disclosure and Certification


A. UCI Investigators: Each Investigator has the responsibility to provide a complete disclosure of all reportable financial interests prior to award receipt and when new reportable significant financial interests are obtained.
Please answer the following questions:





  1. Income

Have you, your spouse or registered domestic partner, and/or dependent children received income or payment for services in the past 12 months directly related to this research project exceeding $10,000 when aggregated? This does not include income from seminars, lectures, teaching engagements, or service on advisory committees or review panels for public or non-profit entities.

 YES  NO






  1. Equity Interests

Do you, your spouse or registered domestic partner, and/or dependent children currently own any equity interest in the form of stock, stock options, real estate, or any other investment or ownership interest exceeding $10,000 in value (current market value if publicly traded; internal estimate of value if not publicly traded) or have more than 5% ownership interest in a single entity directly related to this research project?

 YES  NO






  1. Intellectual Property Rights and Interests

Do you, your spouse or registered domestic partner, and/or dependent children have any intellectual property rights on a patent, patent application, or a copyright of software assigned or to be assigned to a party other than the UC Regents that is directly related to this research project?

 YES  NO

I certify under penalty of perjury that this is a complete disclosure of all my significant financial interests related to this research project and I have used all reasonable diligence in preparing this Financial Interest Disclosure, and to the best of my knowledge it is true and complete. I also acknowledge that by signing my name below that it is my responsibility to disclose any new significant financial interests obtained during the term of the above proposed project.

Signature of Investigator:       ____________________ Date:      _____________

Typed Name:       ____________________ Email (Please Type):       ____________________



(Attach additional sheets as required to identify and include financial disclosure information for all project Investigators.)



Instructions


  1. Any person who is responsible for the design, conduct, or reporting of the proposed project to NSF must submit the Financial Disclosure for NSF-Funded Research (Form 900) at the time of application.

  2. At the just-in-time or notice of award, Conflict of Interest (COI) staff will contact Investigators who have disclosed any significant financial interests (SFI) to request the submission of the Investigator’s Addendum for All Positive Disclosures.

  3. Please allow for sufficient time for the Conflict of Interest Oversight Committee (COIOC) review. The COIOC calendar is available at http://apps.research.uci.edu/oracalendar/.


Definitions


Who is considered an “Investigator,” and therefore required to disclose? “Investigator” means the project director or principal investigator and any other person, regardless of title or position, who is responsible for the design, conduct, or reporting of the sponsored research, which may include collaborators or consultants.
What is an entity? “Entity” means any domestic or foreign, public or private, organization (excluding a Federal agency) from which an Investigator (and spouse and dependent children) receives remuneration or in which any person has an ownership or equity interest.
What is a “Significant Financial Interest”? Anything of monetary value, including, but not limited to:

  1. Income exceeding $10,000 when aggregated for an Investigator, Investigator’s spouse, and dependent children from a single Entity (Business, Public or Nonprofit) including salary, consultant payments, honoraria, royalty payments, dividend, loan, or any other payments or consideration with value during the prior twelve months. Income from a Public or Nonprofit Entity for seminars, lectures, teaching engagements, or service on advisory committees or review panels is exempt;

  2. Equity in the form of stock, stock options, real estate, loan to, or any other investment or ownership interest exceeding $10,000 (current market value) or a 5% ownership interest for any one Entity when aggregated for an Investigator, Investigator’s spouse, and dependent children;

  3. Intellectual property interest held by the Investigator, or Investigator’s spouse or dependent children on a patent, patent application, or a copyright of software assigned or to be assigned to a party other than The UC Regents.

Financial Interest does not include: (1) payments made by the UC Regents (salary, royalties, honoraria, expense reimbursement or any other remuneration); or (2) an investment by a mutual fund, pension fund or other investment fund over which the investigator or his/her immediate family member does not exercise management of fund investment.


What is a “Related Financial Interest”? The work to be performed under the sponsored project and results there from would reasonably appear to be affected by the research or educational activities funded or proposed for funding or in entities whose financial interests would reasonably appear to be affected by such activities. Related financial interests may include, but are not limited to, the following:

  1. The Investigator is conducting a project where the results could be relevant to the development, manufacturing, or improvement of the products or services of the entity in which the Investigator has a financial interest;

  2. The Investigator has a financial interest in an entity which might manufacture or commercialize a drug, device, procedure or any other product used in the project or that will predictably result from the project;

  3. The Investigator has consulting income in his/her professional field that exceeds $10,000 from a single entity during the prior twelve months. The Conflict of Interest Oversight Committee will provide an assessment for the Vice Chancellor for Research as to whether any of that entity’s financial interests, or the Investigator’s financial interests related to consulting for that entity, would reasonably appear to be affected by the federally-sponsored research;

  4. The Investigator has a financial interest in an entity and the sponsored project proposes to subcontract a portion of the work, or lease property, or make referral of participants to, or make purchases from the entity; or

  5. The Investigator has a financial interest in an entity that is part of a consortium or that will otherwise participate in the sponsored project.

Review Process


Staff in Research Administration will review the disclosure information to ensure completeness and consistency. Information provided in the Disclosures of those Investigators having a Related, Significant Financial Interest and additional appropriate documentation shall be forwarded to UCI’s Conflict of Interest Oversight Committee (COIOC). The COIOC will consider whether the financial interests of the Investigator or the Entity could be directly and significantly affected by the proposed sponsored project and whether the financial interest could directly and significantly affect the design, conduct, or reporting of the project. A direct impact occurs when the project results would be directly relevant to the development, manufacturing, or improvement of the products or services of the entity in which the Investigator has a financial interest, or when the entity is a proposed subcontractor or participant in the project. A significant impact on the financial interest is one that will materially affect the value of the organization, its earnings, or the sale of its products. The COIOC will review the disclosure information and make a recommendation to the responsible institutional official.
Records

The information provided herein may be released or transmitted to the sponsor, including federal agency representatives, and according to the California Public Records Act, may also be released to the public, upon request. These records will be retained for 3 years after termination of sponsored project or until resolution of any action by the sponsor, whichever is greater. The Office of Record is the Office of Research.



University of California, Irvine Form 900 – 7/2015


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