Certification for Conflict of Interest Avoidance

Office of Research Compliance

INVESTIGATOR INFORMATION
Name: / Title:
School: / Program/Department:
FINANCIAL INTEREST INFORMATION
Source of Interest: / Areas of Financial Interest:

Because of the situation created by the relationship between my significant outside interest in [SOURCE] and the agreements between UT Dallas and [SOURCE], I acknowledge the possibility for the appearance of a potential conflict of interest between the performance of my duties as a UT Dallas employee, and my obligations to [SOURCE].

I also acknowledge that the Office of Research Compliance may recommend a Conflict of Interest Management Plan to further avoid the perception of a potential conflict of interest. Therefore, I will:

1)  Inform ORC should any changes occur in the nature of my significant outside interest or in the relationship between [SOURCE] and UT Dallas;

2)  Disclose the nature of my significant financial interest in [SOURCE] to UT Dallas students I involve in research projects related to company technology and financial interests;

3)  Strive to differentiate clearly between the research projects I conduct as a UT Dallas employee and my contributions to [SOURCE];

4)  Comply with UT Dallas PP1091, Conflict of Interest, Conflict of Commitment, and Outside Activities, by submitting the required form for review by my department head, dean, or other approval authority; and,

5)  Not disclose to [SOURCE] any confidential or proprietary information owned or created by UT Dallas.

Employee signature: ______

Date: ______

Office of Research Compliance Review

______

Sanaz Okhovat Date

Assistant Vice President, Office of Research Compliance

Rafael Martin

Associate Vice President for Research