ࡱ> RTQ ^"bjbj Qeez,,,8d$,8[l8EGGGGGG$"k99"[ky$EEs"100kk :  CONFLICT OF INTEREST DISCLOSURE FORM FOR SPONSORED PROJECTS Return completed form to the Office of Research and Sponsored Projects, LWH 0006a Name  FORMTEXT      Title and/or Rank  FORMTEXT      College  FORMTEXT      Department/Unit  FORMTEXT      Campus Extension  FORMTEXT     E-mail Address  FORMTEXT       My position on this project is:  FORMCHECKBOX  PI  FORMCHECKBOX  Co-PI  FORMCHECKBOX  Other: FORMTEXT       1. Do you have a consulting or other financial relationship with a sponsor of your research?  FORMCHECKBOX  Yes (If so, please list and explain in an attached statement.)  FORMCHECKBOX  No 2. Do you have a managerial role or a significant financial relationship with a company in a field of your research or a company that does business with the University?  FORMCHECKBOX  Yes (If so, please list and explain in an attached statement.)  FORMCHECKBOX  No 3. Are you engaged in non-University professional or income-producing activities involving either 91Porn students or other staff?  FORMCHECKBOX  Yes (If so, please list and explain in an attached statement.)  FORMCHECKBOX  No 4. Do you, or any members of your immediate family, or any other individual with whom you have a close economic relationship, have any other relationships, commitments, or activities that might present or appear to present a conflict of interest or commitment related to this grant or grant proposal?  FORMCHECKBOX  Yes (If so, please list and explain in an attached statement.)  FORMCHECKBOX  No I have read and I understand 91Porns Investigator Significant Financial Disclosure Policy for Funded Projects, and have made all financial disclosN  " , . B D F P R T x z     F H \ ^ ` h j ӺӺӺӺӺӺjLh#?Ujh#?Ujh#?Ujqh#?Ujth#?Ujh#?UmHnHujh#?Ujh#?U h#?CJhOh#? h#?5\jh#?CJUmHnHu3N|~" , T x " pkd$$Ifl  h0h $0  64 la$If$a$" $ F l $IfpkdY$$Ifl  h0h $0  64 la    " $ @ B D R T p r t 4 5 C D E M N \ ] ^ UV½¡ujkh#?Ujh#?Ujh#?Ujh#?Ujh#?>*UmHnHujh#?>*U h#?>*jh#?>*Uj'h#?Ujh#?Uj?h#?Uh#? h#?CJjh#?U. 3 M T`pkd$$Ifl  h0h $0  64 laVdefBCQRSZ !!!!!!!!!!!!!!""-"."="Z"["\"]"^" hOCJ h&CJ mHnHujh#?CJ U h#?CJ h$jh$U h#?CJh#?6>*]U h#?6]j= h#?Ujh#?UjSh#?Ujh#?Ujh#?Uh#?.AXYZ!!!!k!!!!!!!!!!/"["\"]"^"$a$ $d N ures required by that policy, if any, in an attached statement. I will comply with any conditions or restrictions imposed by the University to manage, reduce or eliminate actual or potential conflicts of interest. 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