900D Financial Disclosure Form
COI Disclosure #________________OSP SC #______________
(Administrative Use Only)
Please type your responses. Incomplete documents will be returned.
UCSC FORM 900D INSTRUCTIONS AND DEFINITIONS
On the following form, you will be asked to certify whether or not you have any Significant
Financial Interests related to your Institutional Responsibilities?
Please use the following information to inform your choices. Additional FAQs are available
from the PHS at this website.
What is a Significant Financial Interest (SFI)? A SFI is any of the following payments:
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With regards to Publicly-Traded Entities, payments or value exceeding $5,000 (aggregated for
family) from a single entity, including salary, consultant payments, honoraria, paid authorship,
equity interest (stock, stock option or other ownership interest) during the prior 12 months.
With regards to Privately Held Entities, payments or value exceeding $5,000 (aggregated for
family) from a single entity during the prior 12 months or when the Investigators hold any
equity interest (stock, stock option, or other ownership interest).
With regards to Intellectual Property, intellectual property rights and interests (patents,
copyrights) upon receipt of income related to such rights and interests.
With regards to Travel Reimbursements, any reimbursed or sponsored travel related to the
Investigator’s Institutional Responsibilities during the prior 12 months that exceeds $5,000 per
entity (with the exception of travel that is reimbursed or sponsored by 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.
A SFI does not include:
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Payments made to you by UC for salary, stipends, royalties, honoraria, reimbursements of
expenses or any other remuneration received from the University, including intellectual
property rights assigned to the Institution and agreements to share royalties related to such
rights;
Mutual funds or other investment vehicles such as retirement funds as long as you do not
directly control the investment decisions;
Income for seminars, lectures, teaching engagements, or service on advisory committees or
review panels sponsored by governments, a US Institution of higher education or an academic
teaching hospital, a medical center, or a research institute that is affiliated with an Institution of
higher education.
Travel costs paid for or reimbursed by governments, a US Institution of higher education or an
academic teaching hospital, a medical center, or a research institute that is affiliated with an
Institution of higher education.
What are “Institutional Responsibilities”? An Investigator’s Institutional Responsibilities
means the Investigator’s professional responsibilities on behalf of the Institution, including
activities such as research, teaching, clinical or other professional practice, academic activities,
scholarly events, institutional committee memberships, and service on panels such as
Institutional Review Boards or Data and Safety Monitoring Boards
University of California, Santa Cruz
* Indicates response required.
Form 900D Revised 10/2/2013
900D Financial Disclosure Form
COI Disclosure #________________OSP SC #______________
(Administrative Use Only)
Please type your responses. Incomplete documents will be returned.
1. Investigator Information
Disclosing Individual*:
Department:
Check One*:
Academic Title:
☐ New Proposal ☐ Annual Reporting/Renewal/Supplemental Funding
☐ New Significant Financial Interests
Email*:
Principal Investigator*:
NIH/PHS Award Number (If different)
NIH Award Title*:
Phone*:
Award Number
OSP SC#*:
2. All investigators must answer the following question:
Do you, your spouse/domestic partner or dependent children have any Significant Financial
Interests related to the Investigator’s Institutional Responsibilities?* See page 1 for definitions.
☐ Yes
☐ No
If you answered YES, please complete the 910 Appendix page(s), sign and submit to your OSP
representative or Principal Investigator. If you answered NO, please sign this form and submit with
your proposal.
Required Training: The same people who are required to disclose their financial interests must
also complete a training session prior to participating in research related to any PHS-funded
project. By reading and acknowledging understanding of the attached materials you will fulfill this
obligation.
☐ I certify that I have read and understood the UCSC COI Training (Follow link for training doc)*
3. Acknowledgment and Certification
University Investigators: By signing below, the Investigator (1) certifies that this form provides an accurate
report of whether or not there are any Significant Financial Interests related to the Investigators’ Institutional
Responsibilities, and (2) acknowledges responsibility to provide a complete disclosure of all Significant
Financial Interests reasonably related to the Investigators’ Institutional Responsibilities prior to award
receipt, as those interests change, and on an annual basis during the project award period.
Signature_____________________________________________________________________
Date_______________________________
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, Santa Cruz
* Indicates response required.
Form 900D Revised 10/2/2013
900D Financial Disclosure Form
COI Disclosure #________________OSP SC #______________
(Administrative Use Only)
Please type your responses. Incomplete documents will be returned.
* Response required.
University of California, Santa Cruz
* Indicates response required.
Form 900D Revised 10/2/2013