Butler Hospital Significant Financial Interests (SFI) Disclosures
Complete this form if you have indicated that you do have Significant Financial Interests on the
CNE Assurance of Compliance form or the CNE Conflict of Interest Disclosure form.
Publicly Traded Entities (received >$5,000 in value from an entity in the preceding 12 months)
1.
a. [Name of entity]
b. [Monetary value]
c. [Nature of service you performed]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
2.
a. [Name of entity]
b. [Monetary value]
c. [Nature of service you performed]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
Non-publicly Traded Entities (received >$5,000 in value or any equity interest from an entity in the preceding 12 months)
1.
a. [Name of entity]
b. [Monetary value and/or amount of equity]
c. [Nature of service you performed]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
2.
a. [Name of entity]
b. [Monetary value and/or amount of equity]
c. [Nature of service you performed]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
Intellectual Property
1.
a. [Name of entity]
b. [Monetary value]
c. [Nature of intellectual property]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
2.
a. [Name of entity]
b. [Monetary value]
c. [Nature of intellectual property]
d. [Indicate whether you think this has any material bearing on your research or hospital activities]
Reimbursed or sponsored travel
1.
a. [Purpose]
b. [Sponsor]
c. [Destination]
d. [Duration]
e. [Monetary value (if available)]
2.
a. [Purpose]
b. [Sponsor]
c. [Destination]
d. [Duration]
e. [Monetary value (if available)]
Other relevant compensation
1. ______.
2. ______.
[Name]
[Date]
2012.12.26