WESTERN ILLINOIS UNIVERSITY
Disclosure of Financial Interests with Regard to Sponsored Projects
Complete either Part a. or Part b., as applicable.
a.
I and/or my spouse/partner and/or any member of my family do not have “Significant
Financial Interests” required to be disclosed according to the Western Illinois University
Conflict of Interest Policy and Procedure with Regard to Sponsored Projects.
I understand and agree to update this disclosure form should my significant financial
interests (and/or those of your spouse/partner or family members) change during the period
of any sponsored research grant or contract funding.
b.
I and/or my spouse/partner and/or any member of my family have “Significant Financial
Interests” required to be disclosed according to the Western Illinois University Conflict of
Interest Policy and Procedure with Regard to Sponsored Projects. These “Significant
Financial Interests” are as follows (please check all that apply and attach additional
documentation as necessary):
Salary or other payments for services (e.g., consulting fees, honoraria, paid
authorship for other than scholarly works) received from a publicly traded company
during the twelve-month period preceding the date on which you are making this
disclosure, and/or an equity interest (e.g., stock, stock options, or other ownership
interest) held in such publicly traded company, when aggregated (for you, your
spouse/partner, and family members) exceeds $5,000. Please explain the nature and
value of this financial interest and how it would reasonably appear to affect or be
affected by your research:
Rumination (including but not limited to, salary, consulting fees, honoraria and paid
authorship for other than scholarly works) received from a non-publicly traded company
during the twelve-month period preceding the date on which you are making this
disclosure, when aggregated, exceeds $5,000. Please explain the nature and value of this
financial interest and how it would reasonably appear to affect or be affected by your
research:
Any equity interest (e.g., stock, stock options, or other ownership interest) in a nonpublicly traded company or business, regardless of value. Please explain the nature and
value of this financial interest and how it would reasonably appear to affect or be
affected by your research:
Holding the position of an officer or other key employee (e.g., CEO, Chief Scientific
Officer, VP for Research) of a company (by you, your spouse/partner, or family
members) for-profit corporation, partnership, business, or other entity outside of the
WIU. Please explain the nature and value of this financial interest and how it would
reasonably appear to affect or be affected by your research:
Intellectual property rights and interests (e.g., patents, copyrights and royalties from
the rights), regardless of value. Please explain the nature and value of this financial
interest and how it would reasonably appear to affect or be affected by your research:
Occurrence of reimbursed or sponsored travel provided that the travel or
reimbursement is not from a federal, state or local government agency, an institution of
higher education, an academic teaching hospital, a medical center, or a research institute
affiliated with an institution of higher education. Please explain the nature and value of
this financial interest, how it would reasonably appear to affect or be affected by your
research, the purpose of the trip, the sponsor/organizer, the destination, and the duration:
I and/or my spouse/partner and/or a family member are involved in outside activities
not identified above which may give the appearance of a conflict of interest. Please
explain the nature and value of this financial interest and how it would reasonably
appear to affect or be affected by your research:
Important: This potential conflict may need to be reviewed by the Provost and Academic Vice
President. To assist the Provost in a timely review of the potential conflict, please
attach a full and complete explanation of the nature of the relationship you (or your
spouse/partner or family member) has with the sponsoring entity or other company in
which you have a financial or ownership interest. Suggested strategies for managing,
reducing, or eliminating the conflict may also be included in the explanation. To
preserve the objectivity of research at WIU, this new research or other activity may not
begin until all financial conflicts of interests have been satisfactorily addressed.
I agree to comply with any conditions or restrictions imposed by the University to manage,
reduce, or eliminate identified conflicts of interest in sponsored research.
Investigator’s Printed Name
Signature
University Title
Department Name
Date
Office of Sponsored Projects Proposal Number
Resolution:
Referred to Provost
No further review required
Compliance Specialist
Signature
Date