Conflict of Interest and Reimbursed or Sponsored Travel Disclosure Form

Instructions:

The information you provide is confidential and will be used only as required to report and manage conflicts of interest as described in OSU Policy and Procedures 4-0130. Return this form directly to the appropriate administrator.

Date Date / MM / DD YYYY
Name Name First Last
Your Email Address
Department
Forward for College COI review (Insert appropriate email address)
1) Do you, your spouse or dependent children have an interest in an entity or activity that
a) does business with the University in an area in which you make spending decisions?
b) profits from the sale of course materials (coursepacks, software, etc.) or other goods or services
to students whom you teach or evaluate?
c) employs University faculty, staff or students who you directly supervise or evaluate both in that
employment and at the University?
d) sponsors a project at the University over which you have any degree of control?
e) profits from research you do at the University?
f) competes with the University for project funding?
g) uses University-owned intellectual property, or University equipment or facilities?
2) Other than those covered in Question 1, do you, your spouse or dependent children have an interest in any entity or activity that
could reasonably appear to affect, or be affected by, the exercise of your University responsibilities?
3) Do you have any interests reported in Question 1 or 2 that are not already subject to a conflict management plan? (Leave blank if no
interests reported.)

3) Do you have any interests reported in Question 1 or 2 that are not already subject to a conflict management plan? (Leave blank if no
interests reported.) All interest are subject to an existing conflict of interest management plan. At least one interest is not subject to an existing conflict of interest management plan.
If you had no interests to report, or if the interests reported are already subject to a conflict of interest management plan, skip
Questions 4 and 5, sign below, and return this form to the appropriate administrator. Otherwise, please complete Questions 4 and 5 and go straight to question 6. A “Yes” to Questions 1 or 2 does not mean that a conflict exists, but you may be asked to provide further information about the activity.
4) Please describe:
a) The nature of the entity or activity (type and name of business, etc.):
b) Your relationship to the entity or activity (including your position or title, if any):
c) The nature of your interest (ownership, salary, equity interest, etc.) and its extent (full ownership, salary in excess of $5000, etc. Please refer to the definition in 3.09):
d) The nature of the potential conflict:
5) Does the interest or your related University responsibility involve receipt of federal funding?
6) Do you provide, or expect to provide during this report year, “professional services” that are related to your University activities to any outside entities? Professional services include but are not limited to consulting, advising, acting as a spokesperson for/or representative of, being employed by or having an appointment with an external entity. Please note that professional services may or may not be compensated (they should be reported either way).

Remunerated scholarship that is an expected activity for being a faculty member in your discipline (such as seminars, lectures or temporary teaching engagements, professional presentations, work on review panels, membership on advisory committees, or activities in professional societies relevant to your field) do not count as external professional services for this question.

ALL non-US temporary or permanent affiliations must be reported.
If “Yes” please describe the activity including organization, organization type, compensation (estimated or actual), the type of activity and the number of days/month devoted (estimated or actual) to the activity.
Reimbursed or Sponsored Travel Disclosure
As Required by PHS Regulations

Instructions:
PHS Regulations require the disclosure of any reimbursed or sponsored travel related to Investigator’s institutional
responsibilities. This disclosure DOES NOT apply to travel that is reimbursed or sponsored by a federal, state, or local
government agency, an Institution of higher education, an academic teaching hospital, a medical center, or a research institute affiliated with an Institution of higher education.
Trip Information (purpose of trip, trip sponsor/organizer, destination, trip duration)
I have read and understood the Oklahoma State University Financial Conflict of Interest Policy and declare that I
have used all reasonable diligence in preparing this disclosure statement, which to the best of my knowledge is
true, accurate, and complete. I understand that under the Policy I have a responsibility to update the above
information throughout the coming year if my circumstances change.
Draw your signature into the box below.

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Conflict of Interest and Reimbursed or Sponsored Travel Disclosure Form

Conflict of Interest and Reimbursed or Sponsored Travel Disclosure Form

Reimbursed or Sponsored Travel Disclosure As Required by PHS Regulations

Reimbursed or Sponsored Travel Disclosure
As Required by PHS Regulations