09/25/2013 Revision
Winthrop University
Disclosure of Financial Interest for Sponsored Projects
Cover Sheet & Instructions
Who must complete this form?
Winthrop University employees, who are involved as investigators, support staff or supervisory officials
in externally funded projects, must disclose to the Winthrop University Research Compliance Officer
(RCO) all significant financial interests of the employee (including those of the employee’s spouse and
dependent children) that reasonably appear to be related to the employee’s institutional responsibilities.
When should the Disclosure of Financial Interest be submitted?
If this is the initial disclosure, the form is submitted along with the Grant Routing and Authorization
Form at the time of a grant submission.
Disclosure forms must be updated annually in compliance with University and Federal policy during the
period of time an employee is involved in external grant programs. The annual update disclosure form
will be due by January 30 of each year an employee continues to be involved in external grant programs.
What must be disclosed?
1. Significant financial interests of $5,000 or more that reasonably appear to be related to the
employee’s institutional responsibilities. See the University policy for a definition of Significant
Financial Interest as well as items excluded from this definition.
2. Any travel reimbursed or paid on behalf of the employee by an external entity, and such travel
expense is related to the employee’s institutional responsibilities, unless this travel is paid by a
Federal, State or local government or by another public university or college.
Conflict of Interest Training
Individuals submitting a Disclosure of Financial Interest form will be required to certify on the
disclosure form completion of the on-line CITI training in Financial Conflict of Interest. Training
certification is valid for four years form the date of certification.
Submission
Complete the Parts 1,2 and 3 if applicable on-line, print form and sign. The signed paper copy should be
submitted to the Research Compliance Officer, either as an attachment to the Grant Routing and
Authorization form with new grant submissions, or as a separate annual update or modification to a
previously submitted form.
Annual updates to the disclosure form are due by January 30 of each year.
Grant proposal submissions will not be accepted unless a current disclosure form is on file with the
Research Compliance Officer.
09/25/2013 Revision
Winthrop University
Disclosure of Financial Interest for Sponsored Projects
Name:
Date:
Winthrop Address:
Department:
Email:
Phone:
Type of Disclosure
Initial Disclosure
Annual Disclosure
Disclosure Modification
Winthrop Position:
Project Role:
Investigator
Support Staff
Supervisory
Part 1
Do you, your spouse or dependent child have any Significant Financial Interests, as defined in the
University Disclosure of Financial Interest policy, related to your institutional responsibilities?
No
Yes; Complete Part 2 of this form
Do you, your spouse or dependent child have any sponsored or reimbursed travel to disclose in
accordance with the University Disclosure of Financial Interest Policy?
No
Yes; Complete Part 3 of this form
Have you completed Conflict of Interest CITI Training within the last four years?
No; You must complete this training before submitting this disclosure form.
Yes
Certification
I affirm that I have read the University’s Disclosure of Financial Interest Policy and agree to abide by its terms.
I further certify that this is a complete and accurate disclosure of any financial interest that I, my spouse or my
dependent children have which would reasonably appear to be related to my university responsibilities.
Type Name
Signature
Date
09/25/2013 Revision
Winthrop University
Disclosure of Financial Interest for Sponsored Projects
Part 2 – Significant Financial Interest (SFI)
Provide the following information for each Significant Financial Interest
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF ENTITY
DESCRIBE BELOW THE NATURE OF THE FINANCIAL INTEREST, INCLUDING THE VALUE OF THE
FINANCIAL INTEREST OR APPROXIMATE VALUE IF EXACT VALUE IS NOT READILY AVAILABLE:
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF ENTITY
DESCRIBE BELOW THE NATURE OF THE FINANCIAL INTEREST, INCLUDING THE VALUE OF THE
FINANCIAL INTEREST OR APPROXIMATE VALUE IF EXACT VALUE IS NOT READILY AVAILABLE:
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF ENTITY
DESCRIBE BELOW THE NATURE OF THE FINANCIAL INTEREST, INCLUDING THE VALUE OF THE
FINANCIAL INTEREST OR APPROXIMATE VALUE IF EXACT VALUE IS NOT READILY AVAILABLE:
09/25/2013 Revision
Winthrop University
Disclosure of Financial Interest for Sponsored Projects
Part 3 – Sponsored or Reimbursed Travel
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF SPONSOR
ORGANIZATION
PURPOSE OF TRIP:
DESTINATION AND
DURATION OF TRIP:
VALUE OF TRIP:
AMOUNT REIMBURSED :
APPROXIMATE VALUE OF TRIP EXPENSES PAID BY SPONSOR:
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF SPONSOR
ORGANIZATION
PURPOSE OF TRIP:
DESTINATION AND
DURATION OF TRIP:
VALUE OF TRIP:
AMOUNT REIMBURSED :
APPROXIMATE VALUE OF TRIP EXPENSES PAID BY SPONSOR:
WINTHROP EMPLOYEE
NAME OF INDIVIDUAL
WINTHROP EMPLOYEE’S SPOUSE
WINTHROP EMPLOYEE’S DEPENDENT
NAME OF SPONSOR
ORGANIZATION
PURPOSE OF TRIP:
DESTINATION AND
DURATION OF TRIP:
VALUE OF TRIP:
AMOUNT REIMBURSED :
APPROXIMATE VALUE OF TRIP EXPENSES PAID BY SPONSOR: