University of St. Thomas
Grants and Research Office
Disclosure of Financial Interests and Management of Conflicts of Interest
Relating to Federal Grant Proposals
Overview. In accordance with federal, state, and applicable sponsor requirements, all investigators must disclose their
personal significant financial interests and those of their family (spouse, registered domestic partner, and/or dependent
children) related to their institutional responsibilities. Please see the second page of this form for instructions and LINK
HERE for additional information on this policy.
Investigator Name
Department
Proposal Name
Disclosure Type:
PRF # GRO
☐ ANNUAL, for the period September 1,
to August 31,
☐ Update, for the disclosure already on file dated
Please answer the following questions to the best of your knowledge as they relate to your institutional
responsibilities:
1. Income. Have you, your spouse or registered domestic partner, and/or dependent children received income or
payment for services in the past 12 months directly related to this research project exceeding $10,000 when
aggregated? This does not include income from seminars, lectures, teaching engagements, or service on
advisory committees or review panels for public or non-profit entities.
☐ Yes
☐ No
2. Equity Interests. Do you, your spouse or registered domestic partner, and/or dependent children own any
equity interest in the form of stock, stock options, real estate, or any other investment or ownership interest
exceeding $10,000 in value (current market value if publicly traded; internal estimate of value if not publicly
traded) or have more than 5% ownership interest in a single entity directly related to this research project?
☐ Yes
☐ No
3. Intellectual Property Rights and Interests. Have you, your spouse or registered domestic partner, and/or
dependent children received any payment for intellectual property rights and interests (e.g., patents and
copyrights) directly related to this research project that, when aggregated, exceeds $5,000?
☐ Yes
☐ No
I certify under penalty of perjury that this is a complete disclosure of all my significant financial interests related to this
research project and I have used all reasonable diligence in preparing this Financial Interest Disclosure, and to the best
of my knowledge it is true an complete. I also acknowledge that by signing my name below that it is my responsibility to
disclose any new significant financial interests obtained during the term of the research project proposed above.
Signature of Investigator________________________________________
Date______________________
Please remit this form to the Grants and Research Office at least one day before your grant proposal is due.
University of St. Thomas
Grants and Research Office
Disclosure of Financial Interests and Management of Conflicts of Interest
Relating to Federal Grant Proposals
INSTRUCTIONS
1. Who must fill out this form?
All investigators on grant proposals or subcontract proposals submitted to a federal entity by the University of St.
Thomas must complete this form prior to submission of the grant application.
2. What should I do with this form once I fill it out and sign it?
Please send the form with original signature to David Steele (AQU 319) at least one day before your proposal is due
at a federal agency.
3. Definitions
The term “investigator” means the principal investigator, co-principal investigators/co-project directors, and any
other person at the institution who is responsible for the design, conduct, or reporting of research or educational
activities funded or proposed for funding by NSF. In short, anyone who is designated as a principal investigator or
key personnel on a grant proposal is considered an “investigator.”
The term “significant financial interest” means anything of monetary value, including, but not limited to, salary or
other payments for services (e.g., consulting fees or honoraria); equity interest (e.g., stocks, stock options or other
ownership interests); and intellectual property rights (e.g., patents, copyrights and royalties from such rights).
4. What are the limitations on the term “financial interest” as used in this form?
“Financial interest” does NOT include:
a) salary, royalties or other remuneration from the University of St. Thomas;
b) income from seminars, lectures, or teaching engagements sponsored by public or non-profit entities;
c) income from service on advisory committees or review panels for public or nonprofit entities;
d) an equity interest that, when aggregated for the investigator and the investigator’s spouse and dependent
children, meets both of the following tests: does not exceed $10,000 in value as determined through reference to
public prices or other reasonable measures of fair market value, and does not represent more than a 5% ownership
interest in any single entity; or
e) salary, royalties or other payments that, when aggregated for the investigator and the investigator’s spouse and
dependent children, are not expected to exceed $10,000 during the twelve-month period.
5. What if I have questions?
Please contact David Steele at 2-6038 or dfsteele@stthomas.edu or AQU 319 if you have any questions about this
requirement or this form.