Significant Financial Interest Disclosure Form
Investigator's Name:
Principal Investigator:
E-Mail:
Phone Number:
Proposal Title:
KFS#:
Department/Organization:
This Disclosure is:
my initial Disclosure
an addendum to my most recent Disclosure
my annual Disclosure
an addendum for travel purposes only to my most recent Disclosure
Purpose
The University of Connecticut is committed to fulfilling its mission to expand human knowledge and benefit
society through research, all in accordance with strict ethical principles. In pursuit of this important goal, the
Financial Conflict of Interest in Research Committee (“Committee”) is charged with identifying and addressing
any potential, actual, and apparent conflicts of interest relating to sponsored research. All faculty and other
investigators that conduct sponsored research are required under federal regulations and UConn Policy to
disclose the financial information requested in this form. A disclosure in and of itself is not suggestive of any
impropriety; rather; it is customary and usual and benefits both the individual and UConn. Indeed, full
disclosure of relevant information and the establishment of a public record are in the best interest of both
UConn and its faculty, employees and students. The Committee works collaboratively with faculty to manage,
reduce, or eliminate any identified potential, actual, or apparent conflicts of interest, and to ensure that no
bias, or the appearance of bias, exists in your research.
UConn requires you to disclose the information in this form in order to comply with UConn’s Financial Conflict
of Interest in Research Policy and to satisfy the disclosure and training requirements mandated by federal and
state regulations, including the Federal Public Health Service (PHS) regulations (42 CFR Part 50 and 45 CFR Part
94) on Promoting Objectivity in Research. Disclosures of financial interests or activities must be based not on
a single grant or research project, but rather on your institutional responsibilities (i.e., educational, research,
research consultation, institutional committee memberships, clinical, service or administrative). The
determination of relatedness of these interests to your research will be made by Research Compliance
Services in collaboration with the Financial Conflict of Interest in Research Committee.
If you are unsure about whether something needs to be disclosed, please contact the Research Compliance
Services FCOI office at fcoi@uconn.edu.
Definitions
Entity: Any non-University of Connecticut, domestic or foreign, public or private, organization (excluding a U.S.
Federal agency) from which you (and your spouse or dependent children) receive remuneration or in which
you have an ownership or equity interest.
Equity: Any stock, stock option, or other ownership interest, whether or not the value can be determined
through reference to public prices or other reasonable measures of fair market value.
Investigator: Principal Investigator and any other person who is responsible for the design, conduct, or
reporting of research.
Remuneration (Reportable Interests): Any payment, cash or in-kind, received from an outside entity in any
form, including, but not limited to: stocks, stock options, bonds, gifts, partnership interests, rights to patent or
royalty payments, consulting fees, honoraria, speaking fees, salary, loans, lectureship fees, fees for serving on
boards of directors, scientific and other advisory boards.
Reimbursed or Sponsored Travel: Travel which is reimbursed to or paid on behalf of the Investigator.
Institutional Responsibilities: Your professional responsibilities on behalf of the University of Connecticut,
such as educational, research, research consultation, institutional committee memberships, clinical, service or
administrative responsibilities.
Non-Reportable Interests include:






Salary support received through University of Connecticut or salary support through University of
Connecticut administered sponsored awards;
Income from investment vehicles, such as mutual funds and retirement accounts, as long as you do not
directly control the investment decisions made in these vehicles;
Travel expenses paid by University of Connecticut or by a sponsored research award to the University
of Connecticut;
Travel reimbursed or sponsored by a 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 seminars, lectures and teaching engagements sponsored by U.S. Federal, state or local
government agencies; U.S. institutions of higher education or U.S. research institutes; U.S. academic
teaching hospitals or U.S. medical centers that are affiliated with U.S. Institutions of higher education;
Income from service on advisory committees or review panels for U.S. Federal, state or local
government agencies; U.S. Institutions of higher education or U.S. research institutes; U.S. academic
teaching hospitals or U.S. medical centers that are affiliated with U.S. Institutions of higher education
1.
Interest in Publicly Traded Entities has to be disclosed if the value of any remuneration received in the past
twelve months, when aggregated, exceeds $5,000 and/or when you have any equity interest in the entity. You only
need to disclose interests that are related to your institutional responsibilities.
NO
YES
(a) During the past 12 months, have you, your spouse or your dependent children received any
remuneration from publicly traded entities that, when combined, amounted to greater than $5,000?
Remuneration includes salary and any payment for services not otherwise identified as salary (e.g.,
consulting fees, honoraria, paid authorship).
NO
YES
(b) Do you, your spouse or your dependent children hold any equity interests in a publicly-traded
entity? Equity interest includes any stock, stock option, or other ownership interest, as determined
through reference to public prices or other reasonable measures of fair market value.
2.
Interest in Non-Publicly Traded Entities has to be disclosed if the value of any remuneration received in the
past twelve months, when aggregated, exceeds $5,000, or when you hold any equity interest in any non-publicly
traded entity. You only need to disclose interests that are related to your institutional responsibilities.
NO
YES
(a) During the past 12 months, have you, your spouse or your dependent children received any
remuneration from non-publicly traded entities that, when combined, amounted to greater than
$5,000? Remuneration includes salary and any payment for services not otherwise identified as
salary (e.g., consulting fees, honoraria, paid authorship).
NO
YES
(b) Do you, your spouse or your dependent children hold equity interests in a non-publicly traded
entity? Equity interests include stock, stock options, or other ownership interests.
3.
Remuneration from Non-Profit Entities has to be disclosed if the value of any remuneration received in the
past twelve months, when aggregated, exceeds $5,000. You only need to disclose remuneration that is related to your
institutional responsibilities.
NO
YES
During the past 12 months, have you, your spouse or your dependent children received any
remuneration from non-profit entities that, when combined, amounted to greater than $5,000?
4.
Income from Intellectual property (IP) Rights has to be disclosed if income received in the past twelve months
that results from, or is related to, your work at the University of Connecticut (e.g., patents, patent applications,
license agreements, copyrights), except when such IP rights income is received from the University of Connecticut.
You only need to disclose income that is related to your institutional responsibilities.
NO
YES
During the past 12 months did you, your spouse, or your dependent children receive any income for
intellectual property rights (e.g., patents, patent applications, license agreements, or copyrights)
resulting from, or related to, your work at University of Connecticut?
5.
Reimbursed or Sponsored Travel greater than $5,000 for any single entity that occurred in the preceding
twelve months has to be disclosed. This does not include travel reimbursed or sponsored by a 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. You only need to disclose reimbursed or sponsored
travel that is related to your institutional responsibilities.
NO
YES
In the past 12 months, have you had any occurrence of reimbursed or sponsored travel (i.e. travel
that is paid on your behalf) that was greater than $5,000 for any single entity?
If you answered “No” to all of the above questions, please go to the last page (Certification).
If you answered “Yes” to any of the questions above, please provide the applicable
corresponding information starting on the next page.
1. PUBLICLY TRADED ENTITIES – You indicated that you have interests in one or more Publicly Traded Entities. Please
record all remuneration below.
Name of Entity
Individual Receiving
Remuneration
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Remuneration
Amount (US$)
Activity/Service
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Please record all Publicly Traded Entities equity interests below.
Name of Entity
Individual Holding
the Equity
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Value (US$)
Type of Equity
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Explain how your responses to Question 1 are related to your institutional responsibilities:

2. NON-PUBLICLY TRADED ENTITIES – You indicated that you have interests in one or more Non-Publicly Traded
Entities. Please record all remuneration below.
Name of Entity
Individual Receiving
Remuneration
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Remuneration
Amount (US$)
Activity/Service
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Please record all Non-Publicly Traded Entities equity interests below.
Name of Entity
Individual Holding
the Equity
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Value (US$)
Type of Equity
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Explain how your responses to Question 2 are related to your institutional responsibilities:

3. NON-PROFIT ENTITIES – You indicated that you have interests in one or more Non-profit Entities. Please record all
remuneration below.
Name of Entity
Individual Receiving
Remuneration
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Remuneration
Amount (US$)
Activity/Service
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Explain how your responses to Question 3 are related to your institutional responsibilities:

4. Intellectual Property Income – You indicated that you have interests related to Intellectual property income. Please record all interests below.
Entity Providing the
Royalty/Payment
Type of IP
Short Description of Invention/IP
IP Status
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
IP Ownership
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Explain how your responses to Question 4 are related to your institutional responsibilities:

5. Reimbursed or Sponsored Travel – You indicated that you have paid travel. Please list all paid travel below. Remember, you do not include travel
reimbursed or sponsored by a 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.
Name of Travel
Organizer/Sponsor
Traveler(s)
Estimated/
Actual
Amount
(US$)
Purpose of Travel
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Explain how your responses to Question 5 are related to your institutional responsibilities:

Start
Date
Trip
Duration
(days)
Destination
Relationship to
Research
Certification:
I certify that I have read and understand University of Connecticut's Financial Conflict of Interest in Research Policy and
that I have completed this Disclosure to the best of my knowledge and belief. Further, I agree to comply with all
applicable regulatory requirements, including the following:







I will ensure that a current financial interest disclosure is on file at time of proposal submission;
I will update this form annually or within 30 days if there is a change in answer to any of the above questions;
If I fail to report a new financial interest within 30 days, I will participate in a retrospective review of my research
as required under federal law;
I will comply with the decisions/requirements of a management plan if the Financial Conflict in Research
Committee issues such plan;
If I am a Principal Investigator, I will appropriately identify individuals (i.e., Investigators) if any, in my proposal
who are responsible for the conduct, design, or reporting of the research. I will take into consideration the role
of the investigator, rather than their title and the degree of independence with which the investigator will work;
If I am a Principal Investigator on a National Institutes of Health award, I will complete my progress report in a
timely fashion to assist in its reporting requirements;
I acknowledge that the University of Connecticut may impose sanctions on me if I fail to comply with applicable
regulations, University of Connecticut policy, or conditions of a management plan.
______________________________________________________________________________
Investigator's Signature
Date