EXHIBIT C
FCOI PUBLIC DISCLOSURE FORM
The following information is required when responding to a request for financial conflicts of interest
(FCOIs). Please complete the following and return to the RTI Privacy Officer.
FCOI Disclosure on [PHS agreement]
Updated on:
In accordance with 42 CFR Part 50 Subpart F, Financial Conflicts of Interest (FCOI) [for PHS
Grants/Cooperative Agreements] 45 CFR Part 94, Responsible Prospective Contractors [for PHS
Contracts], RTI International (RTI) hereby publicly discloses the following significant financial interest as
a FCOI related to the PHS-funded research under [PHS Agreement.] This FCOI was disclosed to [Funding
Source] and is still held by:
o
Investigator’s name:
o
Investigator’s title and role with respect to the research project:
o
Name of the entity in which the relevant SFI is held:
o
Nature of the relevant SFI (e.g., equity, consulting fees, travel reimbursement,
honoraria, etc.):
o
Approximate dollar value of the relevant SFI (dollar ranges are permissible:
$5,000-$9,999; $10,000-$19,999; for 20K<X<100K, use 20K increments;
X>100K, use 50K.)
o
If appropriate: “The SFI is one whose value cannot be readily determined
through reference to reasonable measures of fair market value.”