STUDY00002654 (Befort) / Obesity Treatment Options Set in Primary Care for Underserved Populations

CONFIDENTIAL

University of Kansas Medical Center – Kansas City (KUMC)
CONFLICT OF INTEREST
SECTION I– Study Team Member
Last Name /  First Name /  Middle Name
Name of your Practice/Employer /  Position Title /  Email Address
Your Role in KUMC Research / Name of Primary Investigator with whom you are working.
Christie Befort, PhD
IRB Study Number / Title of Study
STUDY00002654 / Obesity Treatment Options Set in Primary Care for Underserved Populations
DISCLOSURE CRITERIA
1. Financial Interests
Disclose financial interests held by you or family members (reference table at in any organization that reasonably appears to be related to your research activities on this study(e.g. weight loss pharmaceuticals or devices, nutritional products, bariatric surgery services). Disclose equity interests, compensation or intellectual property interests foryourself and immediate and extended family members(spouse, partner, dependent children, non-dependent children, siblings, parents,equivalents by marriage [in laws]). It is unnecessary to disclosesalary or other income from your primary place of employment or activities unrelated to this study.
2.Professional Commitment Interests
Disclose any organization where you or your family engages in professional activities, whether or not you are paid AND which reasonably appears to be related to your research activities on this studywith theUniversity. (e.g. paid or volunteer position of director, officer, board member, volunteer or owner in any organization.)
Disclose professional activities foryourself and immediate and extended family members(spouse, partner, dependent children, non-dependent children, siblings, parents,equivalents by marriage [in laws]). It is unnecessary to disclosecommitments to your primary place of employment or commitments unrelated to this study.
SECTION II- INSTRUCTIONS
  1. Answer the following questions about potential financial interests and professional commitments with externalorganizations according to the Disclosure Criteria.
  2. If you have a new or need to update an existing disclosure, please use Form Bfor each external organization with which you have a Commitment to Professional Interestand/or a Financial Interest according to the Disclosure Criteria. Form B is available at

If you answer “Yes” to ANY item in Section III, disclose the details of those interests using Form B () , submit with this form and sign below
If you answer “No” to ALL items in Section III, sign below
SECTION III- Disclosures
  1. Compensation/Payment:Have you or your family (see definition above) received or do you expect to receive compensation which couldreasonably appear to be related to your research activities with the University?

YesNo
  1. Equity/Ownership: Do you or your family members have an equity or ownership interest which could reasonably appear to be related to your research activities with the University?
YesNo
  1. Intellectual Property: Do you or your family members have intellectual property rights and interests (patents, copyrights, royalties, or license income)that could reasonably appear to be related to your research activities with the University?
YesNo
  1. Sponsored Travel: Have you receivedsponsored or reimbursed travel which could reasonably appear to be related to your research activities with the University? (for yourself only)
YesNo
  1. Professional Commitment Interests: Do you or your family members hold a position of responsibility, whether compensated or not, with an organization which could reasonably appear to be related to your research activities with the University? (e.g. officer, director, associate, proprietor,partner, board member, executive)
YesNo

Section IV - Assurance and Certification Statement

I declare that this report of significant financial interests and personal professional commitments has been examined by me and, to the best of my knowledge and belief, is a true, correct, and complete statement.

  • I understand that failure to file this statement as required or intentionally filing a false statement may result in an adverse impact on the University, the study, and/or my dismissal from the study team.
  • I will report any changes to this statement as soon as they become known to me and no later than 30 days after acquiring a new significant financial interest (e.g. through marriage, inheritance or purchase).
    Sign and date below to confirm that you understand and agree with the above statements:

______

SignatureDate

KUMC Conflict of Interest, FY2015
Questions? Study Team Coordinator:Danielle Christifano, PhD or (913) 945-7890
KUMC Conflict of Interest Program: or (913) 588-1357, (913) 588-1288

Page 1