The University of Melbourne
Melbourne Research Office
CONFLICT OF INTEREST DISCLOSURE FORM
A. INTRODUCTION
The purpose of this form is to facilitate the identification and evaluation of potential conflicts of interest in accord with
University policy. The University does not mandate use of this particular form. Deans and Department Heads may develop
their own pro formas or use other forms of documentation.
University Policy on research-related Conflict of Interest is set out in the Code of Conduct for Research at
http://www.unimelb.edu.au/ExecServ/Statutes/r171r8.html. A researcher must make a full disclosure of a conflict of
interest as soon as reasonably practicable, before taking part in any research project or clinical trial or where the
circumstances of that involvement change. The officer in receipt of the disclosure must discuss the matter with the staff
member concerned and determine a procedure for the management or elimination of the conflict of interest. The procedure
must be documented and the researcher advised in writing. Chief Investigators on certain external research grants may have
specific Conflict of Interest disclosure and management obligations mandated by the funding body, eg in the case of
NHMRC Grants commencing in 2003 NIH Grants. In such cases Chief Investigators must ensure full compliance with
those obligations. Further advice is available at http://www.research.unimelb.edu.au/admin/res.conduct/coi.html.
B. DISCLOSURE
Name of disclosing person:
Department:
Name of person to whom the disclosure is being made:
1. Affiliation or Financial Involvement
Do you (or a close family relation) have an “affiliation” with, or have a “financial involvement”* with, a body which
Question
Is sponsoring your research
Notes (for your use)
Yes
No
Is negotiating with the University a grant/contract in you
which will be involved
Yes
No
May benefit, directly or indirectly, from any inappropriate
control on the dissemination of research results
Yes
No
May benefit, directly or indirectly, from the use of University
resources
Yes
No
May benefit, directly or indirectly, from the formal transfer
of University Intellectual Property
Yes
No
May benefit from the purchase of major equipment,
instruments, materials or other items used to conduct the
research
Yes
No
*A financial involvement includes a direct or indirect financial interest, provision of benefits (such as travel and accommodation) and
provision of materials or facilities.
If yes, please
1. outline the situation,
2.
describe how it might affect or be seen to potentially affect your University research, including the research projects of
your students or academic colleagues, and
3.
explain how you propose to manage this Conflict
2. Clinical Trial Issues
Is the researcher conducting a clinical trial which is sponsored by any person or organisation with a significant interest in
the results of the trial?
If yes, outline the situation
What are the benefits of participation in the trial to the researcher, department and University?
How will the researcher ensure that the sponsorship does not compromise the research and the dissemination of
results?
C. PROCEDURE FOR THE MANAGEMENT OR ELIMINATION OF THE CONFLICT OF INTEREST
To be completed by the Head of Department after discussion with the researcher -
D. CERTIFICATIONS
D1. Researcher (Discloser)
1.
2.
I have disclosed all relevant matters to the Head of Department.
I have agreed to implement the management plan summarized in Part C.
Cross-out if these do not apply:
3. For Chief Investigators on NHMRC grants commencing 2003 - I have met the NHMRC specific
requirements, including an immediate declaration to the Deputy Vice-Chancellor (Research)
4.
For applicants or holders of US Public Health Service (PHS) funding, including NIH grants - I have met
the specific PHS requirements
Signature of researcher: ______________________________________
Date: _______________
D2. Head of Department
1.
2.
I have addressed the situation as required by the Code of Conduct for Research.
I have, where applicable, ensured that the specific requirements of the NHMRC or PHS have been met.
Signature of Head: __________________________________________
Date: _______________
Name of Head of Department: _________________________________________