Last Name
ROSE-HULMAN INSTITUTE OF TECHNOLOGY
CONFLICT OF INTEREST DISCLOSURE
Confidential
1.
I am/my spouse is a director, trustee, officer, or policy-influencing partner or manager of a
corporation, partnership, proprietorship, firm, association, organization, or other entity that is
affiliated with RHIT or otherwise involved in a business relationship with RHIT.
YES
NO
Check one box (Attach additional sheets as needed)
If yes, please identify the corporation or other entity, the nature of the affiliation or RHIT business
relationship, titles held, or functions of position:
2.
I and/or my spouse and/or my dependent children own controlling interest in a corporation,
partnership, proprietorship, firm, association, organization, or other entity that is affiliated with RHIT
or otherwise involved in a business relationship with RHIT.
YES
NO
Check one box (Attach additional sheets as needed)
If yes, please identify the corporation or other entity, the nature of the affiliation or RHIT business
relationship, titles held, or functions of position:
3.
I and/or my spouse are involved in outside activities not identified above which may give the
appearance of a conflict of interest.
YES
NO
Check one box (Attach additional sheets as needed)
If yes, please briefly describe the outside activities and identify the corporation or other entity, titles
held, or functions of position:
See next page
4.
I am an Investigator (project director or any other person regardless of title who is responsible for
the design, conduct, or reporting of research funded by the federal agency which may include
collaborators, subcontractors, and consultants) on an active, pending, or planned external funded
grant/contract or other agreement.
YES
NO
Check one box (Attach additional sheets as needed)
If yes, please check one of the following:
(a) To the best of my knowledge, I and/or my spouse and/or my dependent children do
not have “Significant Financial Interests” required to be disclosed according to the RHIT
Conflict of Interest Policy.
(b) I and/or my spouse and/or my dependent children do have “Significant Financial
Interests” required to be disclosed according to the RHIT Conflict of Interest Policy.
If you checked (b) above, please attach a separate written explanation for each such Significant
Financial Interest.
Describe the nature and the general value of the interest and any other information you think would be
helpful to the RHIT designated reviewer to determine whether a conflict of interest exists. Also, please
list those specific sponsored research projects that could reasonably appear to affect or be affected by
these Significant Financial Interests.
Note: You are not required to disclose the following:
 Salary, royalties, or other compensation from RHIT
 Income from seminars, lectures, or teaching sponsored by 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
 Income from service on advisory committees or review panels sponsored by federal, state, or local
government agencies, 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
 Income from mutual funds and retirement accounts as long as the Investigator does not directly
control investment decisions made in these vehicles
 Ownership interests in businesses funded under the Small Business Innovation Research Program
By signing this disclosure form, I (1) acknowledge I have read and understand the Conflict of Interest
Policy of Rose-Hulman Institute of Technology (RHIT) and to the best of my knowledge my activities are
consistent with this policy; (2) agree to comply with any conditions or restrictions imposed by the
Institute to manage, reduce, or eliminate identified conflicts of interest; and (3) understand and agree to
update this disclosure form should my conflicts of interest (and/or those of my spouse/dependent
children) change before the next disclosure period.
Signature:
Printed Name:
Title and Department (if applicable):
Date:
PLEASE RETURN THIS FORM TO THE APPROPRIATE DESIGNATED REVIEWER