EXHIBIT A
FCOI CLIENT REPORT
Date
Agreement/Contracting Officer
Agency Name
Address
City, State
Subject: Financial Conflict of Interest Notice
Dear
:
As per 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 notifies
you about a manageable FCOI for one of its investigators on the following PHS Grant [Cooperative Agreement,
or Contract].
o
o
o
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Agreement number and title
Name of Project Manager
Name of investigator with the FCOI
Name of the entity with which the investigator has an FCOI
Nature of the SFI
Approximate Value of the SFI (ranges: $5K - $9,999; $10K - $14,999, etc.)
Description of how the significant financial interest (SFI) relates to the PHS funded research and the
basis for RTI’s determination that the SFI constitutes an FCOI; description of the key elements of
RTI’s FCOI management plan, including role and principal duties of the investigator with the FCOI;
conditions of the FCOI management plan; how the FCOI management plan is designed to safeguard
objectivity in the research project; confirmation that investigator agrees with the FCOI management
plan; and how the FCOI management plan will be monitored.
As indicated above, RTI believes it has adequately demonstrated that the described FCOI is manageable, and
with the management plan described, RTI is confident that there is no impact on the investigator’s objectivity
with regard to the indicated PHS Grant [Cooperative Agreement, or Contract]. RTI has also prepared a public
version of this report, available upon written request.
If you have any questions, please feel to call me at (919)
and attention.
Sincerely,
Title
RTI Project Number
, or via email at
. Thank you for your time