FOR FCOI COMMITTEE USE ONLY
FCOI Review Committee
Financial Conflict of Interest Disclosure
For Investigators
Disclosure received in the Graduate School on: Date:_________________
_____Exempt/no relevant disclosures
_____Needs Sub-Committee Review
_____Flagged (expedited initially, determined exempt
thereafter)
_____Needs Full Board Review (continue to items a & b below)
a) FCOI Committee Review Deadline
Date:__________________________
(60 days from receipt in the Graduate School)
b) Actual FCOI Committee review date:
Date:___________________________
Training is due at award stage. Award date:________________________
FCOI Training Completion Date:__________________________
Review Outcome: Found to be FCOI ______Yes ______No
Initials_________
This disclosure is a/an: (must check one below)
_____ Annual Full Disclosure.
_____ Updated Disclosure (disclosure less than 1 year since annual).
______________________________________________________________________________________
SECTION I. Investigator Information
(Investigator means the project director or any other person regardless of title who is responsible for the design, conduct, or reporting
of research funded by any sponsor who requires disclosure of FCOI, which includes all federal agencies.)
Your Name:
Your Institution’s Name:
Department/Unit: _______________________________
Phone:_(___)_____________________
School/College:
Email:
SECTION II. Areas of Scholarly Activities and Pursuit of External Funding:
List or briefly describe the areas of your scholarly activity as well as the areas in which you pursue external
funding
SECTION III. Disclosure Information:
A) In making this disclosure, do NOT include any of the following items, which are excluded from the
definition of significant financial interests (SFI) (See FCOI Policy for a listing of definitions.):
1. salary, royalties or other remuneration paid by SIUE to the investigator for appropriate grant
activity;
2. intellectual property rights assigned to SIUE and agreements to share royalties related to those
rights;
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3. income from investment vehicles such as mutual funds and retirement accounts as long as the
investigator does not directly control the investment decisions made in these vehicles;
4. income from seminars, lectures or teaching engagements sponsored by SIUE or some other federal,
state, or local agency or institution of higher education or academic hospital, medical center or
research institute affiliated with a university;
5. income from service to advisory committees or review panels associated with the same agencies
identified in item 4 above.
B) Identify each company/organization in which you or one of your immediate family members has a
personal financial interest. (Immediate Family means an investigator’s spouse, domestic partner, and anyone who
receives directly or indirectly, more than one half of his or her support from the investigator or from whom the investigator
receives, directly or indirectly, more than one half of his or her support.)
C) Indicate your current or anticipated financial interest.
D) Answer each item YES or NO. For each item answered YES, mark the appropriate annual dollar
amount or estimated value.
E) If you have additional disclosures, attach additional forms as needed. http://www.siue.edu/orp/forms.shtml
1) Company or Organization Name: _______________________________________________________
Is this company or organization publicly traded? YES________
NO
Serve on an advisory board (AB)
Serve on a board of directors (BOD)
Offer consulting services (other than AB or BOD)
Serve in a position in the company
Receive product evaluation payments
Have a publication agreement or receive royalties
for books
Receive fees/honoraria for company sponsored
lectures
Own stocks (excluding diversified mutual funds)
Own stock options or warrants
Have a licensing agreement or receive royalties
for inventions
Other (please describe)
Have partnership or other ownership interest
YES
$0 $4,999
NO_______
$5,000$9,999
$10,000 –
$24,999
$25,000$49,999
>$50,000
Direct Impact*
No**
Yes

Indicate ownership interest (%):
*Indicate if your scholarly activities or receipt of external funding is likely or not to result in an impact or
outcome that directly involves the company.
**If you have marked “No Impact” AND you or an immediate family member has a controlling interest
in the company or organization AND a reviewer could conceive of an apparent overlap with your
interests outlined in Section II, then explain in lay terms why there is no direct impact on a separate
sheet of paper.
After reviewing the table above, neither my immediate family members nor I meet any of the criteria, so I am
reporting that I have no relevant financial disclosures.
Signature:_______________________________________________ DATE:_______________
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SECTION VI. Certification:
Please review your information for accuracy, print the form, sign it, and either email a scanned pdf to
lskelto@siue.edu, fax it to 618-650-3523 or mail it to Linda Skelton, Campus Box 1046, Edwardsville, IL
62026-1046.
By signing this form, I certify that I have read the Southern Illinois University Edwardsville Conflict of Interest
and Commitment Policy 1Q9 (http://www.siue.edu/policies/1q9.shtml) and agree to those terms listed in the
policy. I further certify this disclosure is true and complete to the best of my knowledge. I understand and
agree that it is my responsibility to update my disclosure annually or within 30 days of discovering or acquiring
a new SFI (e.g., through purchase, travel, marriage, or inheritance).
I understand that FCOI files are subject to Federal Audit.
I understand that, if I have any SFI, members of the FCOI Committee are required to review my disclosure for
FCOIs. Every FCOI Committee member has signed a confidentiality agreement.
Investigator Signature
Date
SIUE FCOI Chair Signature (or designee signature)
Date
Form Revised 3/10/15
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