COLORADO SCHOOL OF MINES
1500 Illinois Street
Golden, CO 80401-1887
FINANCIAL INTEREST DISCLOSURE FORM
Investigator’s Name: _________________________________________________________
Department:
_________________________________________________________
Date:
_________________________________________________________
Telephone No.:
_________________________________________________________
Sponsoring Agency:
_________________________________________________________
Proposal Title:
_________________________________________________________
Federal regulations and the Colorado School of Mines Research Conflict of Interest policy require
each investigator to disclose any potential conflict of interest, including any “significant financial
interest” that may be affected by the research you intend to perform. (See definition below.)
Please complete this form and describe any potential conflicts of interest held by you or members
of your immediate family.
DEFINITIONS:
Significant Financial Interest
A “significant financial interest” is anything of monetary value, including, but not limited to: (i)
salary or other payments for services, such as consulting fees or honoraria; (ii) equity interests,
such as stocks, stock options, or other ownership interests; and (iii) intellectual property rights,
such as patents, copyrights, and royalties from such rights. “Significant financial interest” does not
include the following:
(i) salary, royalties, or other remuneration from CSM;
(ii) income from seminars, lectures, or teaching engagements sponsored by public or non-profit
entities;
(iii) income from service on advisory committees or review panels for public or non-profit
entities;
(iv) equity interests that, when aggregated for the investigator, the investigator's spouse, and
the investigator's dependent children, do not exceed $10,000 in value as determined
through reference to public prices or other reasonable measures of fair market value and do
not represent more than a 5% ownership interest in any single entity; or
(v) salary, royalties, or other payments that, when aggregated for the investigator, the
investigator's spouse, and the investigator's dependent children, have not exceeded $10,000
during the preceding twelve month-period and are not expected to exceed $10,000 during
the coming twelve-month period.
Investigator
The “investigator” is the principal investigator of a research project, each co-principal investigator of a research
project, and any other employee or student who is responsible for designing, conducting, or reporting the
research at issue.
SPONSORED RESEARCH FINANCIAL INTEREST DISCLOSURE FORM
1.
In accordance with the Colorado School of Mines Research Conflict of Interest policy (Faculty
Handbook Section 10.4), I am disclosing the following significant financial interest information and
attaching supporting documentation (in an envelope marked “Confidential”) that identifies the business
enterprise or entity involved, and the nature and amount of the interest held by me or members of my
immediate family.
Name of the organization:
_____________________________________________________
Address of the organization:
_____________________________________________________
Telephone number:
_____________________________________________________
Nature of business activity:
_____________________________________________________
Description of “significant financial interest” in this organization:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________.
2.
Please explain how your Colorado School of Mines’ responsibilities (i.e., teaching, research, scholarship
activity, etc.) may be affected by the interest described above. (All related sponsored research
activities must be identified.)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________________________________.
By signing below, I hereby agree to update this disclosure as new significant financial interests
are obtained, and to comply with any conditions or restrictions imposed by the Colorado School of
Mines to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award.
Signature:
_______________________________
Date:
____________________
Printed Name: _______________________________
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