DISCLOSURE STATEMENT
FOR CERTAIN RESEARCH FOUNDATION OFFICERS OR EMPLOYEES*
UPON APPLICATION OF FEDERAL FUNDS
*As defined in the Conflict of Interest Policy
Name
Title of Position
Campus and Department
USE ADDITIONAL SHEETS IF NECESSARY
1. List any office, trusteeship, directorship, partnership, or position of any type, whether
or not compensated, held by you or your spouse with any firm, corporation,
association, partnership or other organization other than the Research Foundation, City
University or State of New York. DO NOT LIST THE AMOUNT.
For those employees whose obligation to file is based on their application for or
continuation of federal funding, only those affiliations held by you, your spouse or
dependent children should be reported that would reasonably appear to affect or be
affected by the research or educational activities funded or proposed for funding by the
sponsor.
Self/Spouse
Name of Organization
Dependent Children and address
Position
Description
2. List name and describe the nature and source of any current employment or occupation
of spouse and dependent children.
For those employees whose obligation to file is based on their application for or
continuation of federal funding, only that employment should be reported that would
reasonably appear to be affected by the research or educational activities funded or
proposed for funding by the sponsor.
Source
Nature
3. List the name of warrants or stocks, and other investment interests including any
interests in limited or general partnerships owned by you, your spouse or dependent
children at time of filing for federal funding. DO NOT LIST AMOUNTS.
For those employees whose obligation to file is based on their application for or
continuation of federal funding, only those interests should be reported that would
reasonably appear to be affected by the research or educational activities funded or
proposed for funding by the sponsor.
Self/Spouse/Dependent Children
Issuing Entity
I declare that the above information is true and correct, and I acknowledge that I must
update this form annually.
Signature
Date
Attachment A
Policy No: 522B
CONFLICT OF INTEREST
POLICY
Date Issued: Date Revised:
3/12/81
12/09/96
The Research Foundation by its Board of Directors adopts this Conflict of Interest policy. The
following statement sets forth the policy, defines applicability, provides guidelines, describes the
process for disclosure of possible conflicts of interest and sets forth the sanctions for violation of
the policy.
APPLICABILITY
As used in this document, the term "Research Foundation" or "Foundation" will mean The
Research Foundation of the City University of New York.
The terms "officer" and "employee" will include any person employed by, representing or acting
on behalf of the Research Foundation, or who is in a significant decision making capacity with
respect to the professional, technical or scientific aspects of a program or project conducted or
administered through the Foundation.
POLICY
No officers or employees of the Research Foundation should have any interest, financial or
otherwise direct or indirect, or engage in any business or transaction or professional activity or
incur any obligation of any nature, that is in substantial conflict with the proper discharge of their
duties in the best interests of the Research Foundation.
GUIDELINES
1. No officers or employees of the Research Foundation will accept other employment which will
impair their independence of judgment in the exercise of their duties and responsibilities.
2. No officers or employees of the Research Foundation will accept employment or engage in any
business or professional activity which will require them to disclose information confidential to the
Foundation which they have gained by reason of their position or authority, unless required to do
so by law.
3. No officers or employees of the Research Foundation will use their position to secure undue
privileges or exemptions for themselves or others.
4. No officers or employees of the Research Foundation will engage in any transaction as a
representative or agent of the Research Foundation with any business entity in which they, their
spouse or any dependent, or any business partners have a direct or indirect financial interest that
might conflict with the proper discharge of responsibilities.
5. No officers or employees of the Research Foundation or corporation, firm or association of
which such person, their spouse or any dependent, or any business partner is a member, shall
sell, contract for or provide goods or services to the Research Foundation in connection with a
program or project administered through the Foundation in a manner which is inconsistent with
the Foundation's established procurement policy.
6. Officers and employees of the Research Foundation will abstain from holding personal
investments in enterprises which they have reason to believe may be directly involved in
decisions to be made by them or that will otherwise create a conflict between their duties in the
best interest of the Research Foundation and their private interests.
7. Officers and employees will disclose in accordance with procedures any significant financial
interest that would reasonably appear to be affected by the activities conducted by the Research
Foundation.
DISCLOSURE REQUIREMENT
The document entitled, "Disclosure Statement" which is made a part of this Conflict of Interest
policy as Attachment "A" must be completed by any principal investigator(s) or co- principal
investigator(s) applying for funds from an agency of the federal government requiring completion
of a Disclosure Statement and who has not filed a disclosure statement in conformance with New
York State Public Officers Law sec.73-a and 73, 74 as applied by The City University of New York
(CUNY) campuses in accordance with accepted practice (CUNY II form). Employees and officers
of the Research Foundation's Central Office will file with the President of the Research
Foundation or the President's designee, hereafter the Foundation institutional representative.
PROCEDURES
All real, apparent or potential conflicts of interest defined under the guidelines must be disclosed
for review and determination as to whether a violation of this Policy exists.
Authorities
1. Each CUNY campus will have a designated representative to whom the disclosure will be
made. The representative will be named by the College President and that person's name and
title will be given to the Research Foundation's institutional representative. Any changes in this
designation will also be sent to the institutional representative. For officers and employees of the
Central Office of the Research Foundation, disclosure will be made to the Foundation institutional
representative.
2. The Campus representative shall review disclosure documents for all real, apparent or
potential conflicts as they pertain to Research Foundation activities.
3. The Research Foundation will establish a Conflict of Interest Committee with responsibilities as
enumerated below for the management, reduction or elimination of any conflict of interest.
The Committee will consist of the following:
-President of the Research Foundation
-Two representatives of the Faculty Advisory Council
-One designee from the University from the University Council of Provosts
-One designee from the Grants Officers Council
- Research Foundation's Labor Designee
Conflict Resolution
4. Where a conflict of interest as defined by the Research Foundaton Policy is discovered,
appropriate steps must be taken to manage, reduce or eliminate such conflict of interest. These
steps may include: a) public disclosure of significant financial interests; b) monitoring of research
activities by independent reviewers c) modification of research/work plan; d) disqualification for
participation in the portion of the sponsored program that would be affected by the significant
financial interest; e) divestiture of the significant financial interest; f) severance of relationships
that create actual or potential conflict; g) the program may be allowed to go forward without
imposing such conditions or restrictions if the apprpriate authority, as provided below, determines
that imposing conditions or restrictions would be either ineffective or inequitable, and that the
potential negative impact that may arise from significant financial interests are outweighed by
interests of scientific progress, technology transfer or the public health and welfare.
Complaints and Inquiries
5. In the event of a real, apparent or potential conflict involving an officer or employee whose
work location and/or faculty/staff affiliation is at a campus of the University, the campus
representative shall immediately advise the campus president and the Foundation institutional
representative of the determination of such conflict. The campus administration shall take initial
responsibility to manage, reduce or eliminate the conflict in accordance with Foundation policy
(Procedures - paragraph 4, above), and shall inform the Foundation institutional representative of
its resolution. The institutional representative can accept this resolution, or may call for review by
the conflict of interest committee.
6. In the event of a real, apparent or potential conflict involving an officer or employee of the
Central Office of the Foundation, the institutional representative shall immediately advise the
Foundation president of the determination of such conflict. The Foundation administration shall
take initial responsibility to manage, reduce or eliminate the conflict in accordance with
Foundation policy (Procedures - paragraph 4, above).
Appeal
7. In the event that the Foundation institutional representative does not accept the campus
resolution of a conflict, or in the event an officer or employee chooses to appeal a conflict
resolution at the campus, the conflict of interest matter will be brought to the attention of the
Conflict of Interest Committee for investigation and resolution.
8. The Committee in its investigation will afford the affected individual(s) confidential treatment to
the maximum extent possible. The individual will also be afforded the opportunity to address the
Committee to comment on any allegations or findings resulting from the investigation.
Process
9. Each review by the Campus representative must be completed within 30 calendar days from
receipt of disclosure, and each campus resolution of a determination of conflict should be
concluded within 60 days thereafter, including preparation of a written report. Each Committee
investigation must be initiated within 30 calendar days of the time the issue is brought to the
committee for resolution. Investigations must be complete within 120 calendar days.
10. Detailed documentation of each review by the Campus representative and each campus
resolution must be retained for three years. Documentation to substantiate the Committee's
investigation findings must be retained for three years after the completion of the final report.
11. The Institutional representative of the Research Foundation will be responsible for notifying
the appropriate agency of any conflict of interest that can not be managed, reduced or eliminated
through these procedures, as well as for carrying out any other reportage requirements of the
agency.
12. Appropriate interim administrative actions will be taken to protect Research Foundation and/or
sponsored program assets and funds, and to ensure that the purpose of any programs for which
financial assistance is given are being carried out.