BOSTON COLLEGE
Disclosure Statement
Regarding External Affiliations
Name:
Title/Rank:
School/Department:
Title of Sponsored Project:
Name of Funding Sponsor:
Project Period:
Certification: I have read and understand the Boston College Conflict of Interest Policy
Pertaining to Sponsored Projects.
Please Respond by Inserting an “X” in the appropriate boxes:
1. Are you or any member of your immediate family (spouse or domestic partner and/or dependent
children) an officer, director, partner, trustee, Employee, advisory board member, or agent of (a)
the external organization funding this Sponsored Project or (b) any external organization from
which goods and services will be obtained under this Sponsored Project (including those to which
you may be subcontracting a portion of the project work), (c) any external organization whose
financial condition could benefit from the results of this Sponsored Project, or (d) any external
organization having business dealings in an area related to he work under this Sponsored Project??
yes (if so, describe in detail the nature and extent of the association on an attached
sheet).
no.
2. Are you or any immediate family member the actual or beneficial owner of more than five percent
(5%) of the voting stock or controlling interest of (a) the external organization funding this
Sponsored Project or (b) any external organization from which goods and services will be obtained
under this Sponsored Project (including those to which you may be subcontracting a portion of the
project work), (c) any external organization whose financial condition could benefit from the results
of this Sponsored Project, or (d) any external organization having business dealings in an area
related to he work under this Sponsored Project??
yes (if so, describe in detail the nature and extent of the equity interest on an
attached sheet).
no.
2
3. Have you or any member of your immediate family derived income within the past year, or do you
or any member of your immediate family anticipate deriving income, exceeding $10,000 per year
from (a) the external organization funding this Sponsored Project or (b) any external organization
from which goods and services will be obtained under this Sponsored Project (including those to
which you may be subcontracting a portion of the project work), (c) any external organization
whose financial condition could benefit from the results of this Sponsored Project, or (d) any
external organization having business dealings in an area related to he work under this Sponsored
Project? Do not include funds that would pay your university salary under the Sponsored Project
budget.
yes (if so, describe on an attached page the amount of the income and the reason for
which it was or will be derived).
no.
4. Do you have any personal business affiliation with an external organization whose interests are
related to this project that cover identical or similar work that will be funded by a sponsored
agreement; or have you involved or will you involve any student to assist you in the work covered
by a consulting or other personal agreement with a business?
yes (if so, describe on an attached page the nature of the affiliation and the amount of
time per week you dedicate to it).
no.
5. Does this project involve research with human participants?
Yes
No
Signature:
Date:
123113
Important Note: The Principal Investigator must also ensure that those who are responsible
for, or in a position to influence, the design, conduct, or reporting of research or other
scholarly activity will also complete and submit disclosures and updates in accordance with
Conflict of Interest Policy Pertaining to Sponsored Projects.