IRB Conflict of Interest Disclosure

A conflict of interest is whenever an investigator has a significant financial interest in a research project. A financial interest is defined as anything of monetary value, including, but not limited to: 

  • Salary or other payments for services (e.g., consulting fees or honoraria); 
  • Equity interests (e.g., stocks, stock options, or other ownership interests, excluding any interest arising solely by reason of investment in a business by a mutual, pension, or other institutional investment fund over which the investigator or his/her immediate family does not exercise control); 
  • Intellectual property rights (e.g., patents, copyrights, and royalties from such rights).  

The term does NOT include:  

  • Salary, royalties, or other remuneration from the University;  
  • Income from seminars, lectures, or teaching engagements sponsored by public or non-profit entities;  
  • Income from service on advisory committees or review panels for public or non-profit entities;
  • An equity interest that when aggregated for the investigator and the investigator’s spouse and dependent children meets both of the following tests: Does not exceed $5,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and does not represent more than a 5% ownership interest in any single entity; or,  
  • Salary, royalties, or other payments that when aggregated for the investigator and the investigator’s spouse and dependent children over the next 12 months are not expected to exceed $5,000.  

1. In the twelve months preceding this disclosure, did you or any member of your immediate family (spouse, domestic partner, or dependent children) receive remuneration related to your institutional responsibilities from a:

  • Publicly traded entity that exceeds $5,000?

                                         OR

  • Non-publicly traded entity that exceeds $5,000? 

2. Have you or any member of your immediate family (spouse, domestic partner, or dependent children) received any income from intellectual property rights and interests related to your institutional responsibilities? 

3. In the twelve months preceding this disclosure, has any organization sponsored or reimbursed you for any travel you have taken that is related to your institutional responsibilities?

(Do not include 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 that is affiliated with an institution of higher learning.)

Certification & Signature

By signing this form, I certify the following: 

  • The answers to these questions are accurate and truthful to the best of my knowledge. 
  • I will promptly file a new disclosure form if the answers to any of these questions change. 
  • I will comply with all applicable regulations, Franklin University policies, sponsor requirements, and any conflict of interest management and oversight plans issued by the University. 
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