For DRC Use Only: #
Financial Conflict of Interest in Research (FCOIR) Disclosure Statement
Your financial and other personal information on this form will be treated as confidential and will not be disclosed
outside the Disclosure Review Committee and its staff without your consent except pursuant to a judicial order or
lawfully issued subpoena. The University will make reasonable efforts to notify you of any judicial order or lawfully
issued subpoena in advance of disclosure of this information, unless the order is from a federal grand jury or is for law
enforcement purposes and its terms prohibit the University from disclosing its existence or contents.
For complete information, see the UNH Policy on Financial Conflict of Interest in Research at
http://usnholpm.unh.edu/UNH/VIII.Res/E.htm. Instructions for completing this form are available at
http://www.unh.edu/research/sites/unh.edu.research/files/fcoi_disclosure_statement_instructions.pdf
(For research projects proposed for funding by the Public Health Service [PHS}, do not complete this
form; please see the UNH Policy on Financial Conflict of Interest in Research for PHS-Funded Projects at
http://www.usnh.edu/olpm/UNH/VIII.Res/T.htm and the Disclosure Statement for Financial Conflict of
Interest in Research for Projects Funded by the PHS at http://www.unh.edu/research/conflicts-interestcommitment.) Please contact the Office of the Senior Vice Provost for Research (OSVPR) at (603) 8621948 with any questions.
NAME ____________________________DEPARTMENT _______________________
EMAIL ADDRESS _________________________________________________
PROPOSAL TITLE ______________________________________________________
PROPOSAL* SUBMITTED TO _____________________________________________
(Sponsor)
POSITION ON PROJECT _________________________________________________
(Principal Investigator, Co-Investigator, etc.)
*Please attach to this form an abstract of the research being proposed.
1. Does this research involve use of human subjects? ____ No ____ Yes**
**A “Yes” response will prompt notification of the Chairperson of the Institutional Review Board for the
Protection of Human Subjects in Research about the information contained in this form and any
supporting materials.
2. What is the name of the external entity in which you and/or your family member(s)
have a significant financial interest?
3. This entity is a: ___Publicly-traded for-profit ___Privately-held for-profit ___Non-profit
4. Briefly describe the primary business of this entity.
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5. Explain who holds the financial interest, and describe the role of you and/or your
family member(s) with this entity (e.g., shareholder, director, officer, employee).
6. If applicable, describe the nature of the work that you and/or your family member(s)
perform for this entity.
7. Indicate the aggregate amount of income/compensation from this entity in the
preceding 12 months by checking the appropriate box:
□ Less than $10,000
□ More than $10,000
□ Not applicable
8. Indicate the type of financial interest you and/or your family member(s) has regarding
this entity (check all applicable items):
a.
□
Stock, stock option, partnership share or other ownership interest
Please indicate the aggregate fair market value and percentage of ownership interest by checking
the appropriate boxes:
□
□
b.
c.
d.
e.
Less than $10,000
More than $10,000
□
□
Less than a 5% ownership interest
More than a 5% ownership interest
□
Intellectual property, such as pending patent applications (including provisional
applications), issued patents, trademarks, or copyrights, or royalties received for intellectual
property Please describe the intellectual property to which these interests are related, and any
associated agreements with UNH, including licenses.
□
□
□
Consulting income from entity
Service in an executive position for a business, or compensation for service on boards
Salary as an employee
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f.
g.
h.
□
□
□
Payments for editing, lectures, commissioned papers, or expert testimony
Gifts, gratuities, favors or anything of monetary value
Other significant financial interest(s) that may affect or be perceived to affect the results of
the research activities funded or proposed for funding.
Please explain items c through h.
9. Please describe the relationship among the sponsor, UNH, and the entity in the
proposed project (e.g., UNH will be the prime recipient of funds and will subcontract to
the entity). As part of the description, please explain/diagram the flow of money from
the point of origin (i.e., sponsor) to the recipient organization(s).
10. Does/will this entity or any of its employees use UNH space/facilities or equipment on
behalf of the entity? ____ No ____ Yes. If Yes, describe the resources to be used and
indicate whether there is a written agreement between UNH and the entity to manage
their use (if yes, please attach a copy of the agreement).
11. Is there a current Management Plan in place for your financial interest in this entity?
____ No ____ Yes
In signing and submitting this form, I certify:
•
•
•
•
•
The information provided above is true to the best of my knowledge.
The information provided above provides an accurate statement of all financial interests held by me
and/or my family member(s) that would reasonably appear to affect or be affected by the proposed
research.
I will update this disclosure during the period of the award as new reportable significant financial
interests are obtained.
I will comply with any conditions or restrictions imposed by UNH to manage, reduce, or eliminate
actual or potential conflicts of interest, or forfeit the award.
If a financial conflict of interest is identified, a conflict management plan will be fully executed prior
to expenditure of any sponsored project funds.
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•
If a conflict of management plan is required, I will complete UNH’s conflict of interest and
commitment Web-based training prior to expenditure of any sponsored project funds.
Signed: ____________________________
Date __________________
Please submit the project abstract and any other documentation in a sealed envelope marked confidential to: Office of
the Senior Vice Provost for Research, Thompson Hall, Room 107, 105 Main Street, Durham, NH 03824-2512.
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