Significant Financial Interest Review Form
(Form 1)
Revised 01/22/15
Principal investigators (PIs) and any other individuals with responsibility for design, conduct, or reporting of a project
(“Investigators”) must disclose Significant Financial Interests of themselves, their spouse, and dependent children
where that financial interest may be: 1) affected by the research being conducted or, 2) in any organization that
would reasonably appear to be affected by or benefit from the research being conducted.
Disclosure is required at the time a new proposal is submitted (and annually thereafter if proposal is funded) and
whenever there is a change in the Significant Financial Interest, as defined on page 2 under Definitions.
The University of Connecticut’s Conflict of Interest policy can be found here: http://policy.uconn.edu/?p=382
Investigator Name
Date
Department
School
Phone Number
E-mail address
Proposal Title
Amount Requested
Submitted to (Sponsor)
Project Start Date
Project End Date
If you are the Co-PI, who is the PI?
If this is an
Existing Grant, a
Continuing Grant, or a
Supplement, what is the KFS #
Does this research involve human subjects?
Does this research involve animal subjects?
YES
NO
YES
NO
I. DISCLOSURE - SIGNIFICANT FINANCIAL INTEREST
Based on the definitions of “Significant Financial Interest” from page 2, have you (“you” meaning you, your
spouse, or dependent children) had in the past 12 months, currently have, or expect to have in the next 12
months, a Significant Financial Interest that reasonably appears to be related to your Institutional
responsibilities or that would reasonably appear to be affected by the research for which funding is sought or
are in entities whose financial interests would reasonably be affected by the research?
(Note: Examples of significant financial interests include equity or ownership interests or projected annual
income of an investigator, an investigator’s spouse or dependent children valued at greater than $5,000 or an
equity or ownership interest of more than 5% in a single publicly traded entity or any equity ownership in a single
private entity. See page two for greater detail.)
YES A Significant Financial Interest may exist, and I agree to submit a Supplemental Significant Financial
Interest Disclosure Form for review by the Financial Conflict of Interest in Research Committee (FCOIRC) not less
than 30 days prior to the project start date, with a copy of this Review Form attached.
NO A potential Significant Financial Interest does not exist at this time. I agree to submit an updated
Significant Financial Interest Review Form / Supplemental Significant Financial Interest Disclosure Form, as
needed, should circumstances change.
II. CERTIFICATION - I certify that the above information is complete and true to the best of my knowledge and
that I have read the UConn Conflict of Interest policy. I acknowledge that I am responsible for submitting
updates to this information within 30 days of any change.
Signature
Date
(Original Signature ONLY (required – a “per” signature is not acceptable)
To be completed by SPS SPS # __________________
FCOI # _____________________
Page 1 of 3
Significant Financial Interest Review Form
(Form 1)
Revised 01/22/15
DEFINITIONS
Significant Financial Interest (SFI) - PHS funding:
 With regard to any publicly traded entity, an SFI exists if the value of any remuneration* received from the entity
in the twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of
disclosure, when aggregated, exceeds $5,000; or
 With regard to any non-publicly traded entity, an SFI exists if the value of any remuneration received from the
entity in the twelve months preceding the disclosure, when aggregated, exceeds $5,000, or when the Investigator
(or the Investigator’s Immediate Family) holds any equity interest (e.g., stock, stock option, or other ownership
interest); or
 Intellectual property rights and interests (e.g., patents, copyrights), upon receipt of income related to such rights
and interests.
 Investigators also must disclose the occurrence of any reimbursed or sponsored travel (i.e., that which is paid on
behalf of the Investigator and not reimbursed to the Investigator so that the exact monetary value may not be
readily available), related to their Institutional Responsibilities.
Significant Financial Interest (SFI) - Non-PHS funding:
 An equity interest that when aggregated for the Investigator and the Investigator’s Immediate Family exceeded
$5,000 over the last 12 months, and/or is expected to exceed $5,000 in value over the next 12 months as
determined through reference to public prices or other reasonable measures of fair market value; or when the
Investigator (or the Investigator’s Immediate Family) holds a 5% or greater equity interest (e.g., partnership,
ownership, stock, stock option, or other ownership interest) in a single publicly traded entity or holds any equity
interest in a non-publicly traded entity; or
 Salary, royalties or other payments not from the University for services (e.g., consulting fees or honoraria) that
when aggregated for the Investigator and the Immediate Family over the last 12 months exceeded $5,000 or are
expected to exceed $5,000 over the next 12 months.
Investigators governed by FDA regulations would also have a Significant Financial Interest if one or more of the following
apply:



Compensation made to the investigator in which the value of compensation could be affected by the outcome of
the study/research project.
A proprietary interest in the tested product, including but not limited to, a patent, trademark, copyright or
licensing agreement.
Significant payments of other sorts, which are payments that have a cumulative monetary value of $25,000 or
more made by the sponsor of a covered study to the investigator or the investigators' institution to support
activities of the investigator exclusive of the costs of conducting the clinical study or other clinical studies, (e.g., a
grant to fund ongoing research, compensation in the form of equipment or retainers for ongoing consultation or
honoraria) during the time the clinical investigator is carrying out the study and for one year following completion
of the study.
The term Significant Financial Interest does not include the following types of financial interests:


Salary, royalties, or other remuneration paid by the Institution to the Investigator if the Investigator is currently
employed or otherwise appointed by the University, including intellectual property rights assigned to the
University and agreements to share in royalties related to such rights;
Income from investment vehicles, such as mutual funds and retirement accounts, as long as the Investigator does
not directly control the investment decisions made in these vehicles;
Page 2 of 3
Significant Financial Interest Review Form
(Form 1)
Revised 01/22/15



Income from seminars, lectures, or teaching engagements sponsored by a federal, state, or local government
agency, an institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical
center, or a research institute that is affiliated with an Institution of higher education; or
Income from service on advisory committees or review panels for a federal, state, or local government agency, an
Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or
a research institute that is affiliated with an institution of higher education.
Travel that is reimbursed or sponsored by a federal, state, or local government agency, an Institution of higher
education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute
that is affiliated with an Institution of higher education.
*Remuneration includes salary and any payment for services not otherwise identified as salary (e.g., consulting fees,
honoraria, paid authorship); equity interest includes any stock, stock option, or other ownership interest, as determined
through reference to public prices or other reasonable measures of fair market value
Page 3 of 3