Significant Financial Interests Disclosure Form

Please read Lewis & Clark College's Financial Conflict of Interest Policy prior to completing this form.

The following disclosure is made pursuant to the requirements of the regulation Responsibility of Applicants for Promoting Objectivity in Research for which Public Health Service Funding is Sought (42 CFR Part 50 and 45 CFR Part 94), and the requirements set forth by the National Science Foundation. This disclosure must be completed 1) prior to the submission of a grant application to a federal funding agency to which this policy applies, 2) updated annually, and 3) within 30 days of acquiring or discovering any new reportable significant financial interests. Investigators joining the College who are conducting research sponsored by the agencies to which this policy applies should complete this form within 30 days.

Significant financial interests that could directly affect the design, conduct, or reporting of research must be disclosed. Lewis & Clark College will review disclosures to determine if financial interests may create an actual or potential financial conflict of interest with the project and/or the institutional responsibilities of the investigator(s). Federal regulations require that financial conflicts of interest are appropriately reported and managed. The disclosure period is the twelve months preceding the date of disclosure.

Email address

Investigator (first and last name)

Department

School/Division

Definitions

Significant Financial Interest (SFI) is defined as one or more of the following that reasonably appears to be related to the investigator’s institutional responsibilities:

a) Publicly traded entities: if the value of any remuneration received in the 12 months preceding the disclosure AND the value of any equity interest (e.g., stock, stock option, or other ownership interest) at the time of disclosure, when aggregated, exceeds $5,000

b) Non-publicly traded entities: if the value of any remuneration received in the 12 months preceding the disclosure, when aggregated, exceeds $5,000 OR when the Investigator (or the Investigator's spouse or dependent children) holds ANY equity interest, regardless of dollar value;

c) intellectual property rights and interests (e.g. patents and copyrights) upon receipt of income related to such rights and interests;

d) any reimbursed or sponsored travel (i.e., paid on behalf of the investigator) and not reimbursed to the Investigator so that the exact monetary value may not be readily available), related to their institutional responsibilities;

3) All foreign interests (e.g. income from lectures, teaching engagements, reimbursed sponsored travel) from any foreign entity, when income exceeds $5,000.

For the purpose of this disclosure form, "Institutional Responsibilities" means an Investigator’s professional responsibilities on behalf of Lewis & Clark, which include teaching, research, research consultation, institutional committee memberships, and other service.

The term does not include a) salary, royalties or other remuneration from Lewis & Clark College, including intellectual property rights assigned to the College and agreements to share in royalties related to such rights; b) income from seminars, lectures, teaching engagements, or service on advisory committees or review panels sponsored by a federal, state, or local government agency, a U.S. institution of higher education, a teaching hospital, medical center, or research center affiliated with an institution of higher education; or c) income from investment vehicles, such as mutual funds or retirement accounts, as long as the investigator does not directly control the investment decisions made in these vehicles. These financial interests are not included in the definition regardless of total dollar amount (the threshold amount is not applicable due to the source of funding).

Investigator is defined as the Principal Investigator and any other person responsible for the design, conduct, or reporting of research, educational, or service activities funded, or proposed for funding. For the purposes of this disclosure requirement, the term "investigator" includes the investigator's spouse and dependent children.

Acknowledgement & Certification

By submitting this form I certify that all of the information contained herein is true, accurate and complete to the best of my knowledge. I have read, understand and agree to comply with the College's policy regarding Significant Financial Interests.

I acknowledge that by signing my name below that it is my responsibility to disclose within 30 days of discovering or acquiring any new Significant Financial Interest . I am aware that I will be required to complete training on this policy every four years, and that I will be required to complete this form at least annually. If Lewis & Clark College determines that a Financial Conflict of Interests exists, I will comply with any conditions or restrictions imposed to manage any real or perceived conflicts.

Electronic Signature

Please type full legal name to certify this form

Certification Date