NAME

FORM 1
CONFLICTS OF INTEREST
ASSURANCE OF COMPLIANCE
Utah State University
Office of the Vice President for Research

Please complete and return to YOUR DEPARTMENT
by October 22, 2010

Assurance Statement

Information pertinent to Utah State University's (USU's) policies regarding Conflicts of Interest are found in the following documents: (1) Conflict of Interest Policy 307; (2) Academic Freedom and Professional Responsibility Policy - Standards of Conduct, Policy 403.3.3; (3) Consulting Leave Policy 377; (4) Intellectual Property and Creative Works Policy 327; (5) Utah Code 67-16-1; and (6) Title 42 CRF 50.601. Faculty and academic researchers are required to assure their compliance with these policies. To do this, please answer the questions below and sign in the appropriate block at the end of the form.

When answering the questions, the term “you” applies to you, your first degree relatives (spouse, parents, children and siblings), and your in-laws. If you have any questions or are unsure about how to respond to any of the items below, you should discuss your concerns with your direct supervisor or USU's Federal Compliance Manager, Russ Price, at 797-8305.

Screening Questions

  1. Do you or any member of your family have any involvement or financial interest that is, or could be perceived to be, in conflict with the discharge of your duties at the University?

Yes No

  1. Do you spend beyond three days per month or 36 days per year on external professional or commercial activities (e.g., external consulting, intellectual property development, or sponsored projects that you are performing for a commercial purpose) during periods of University obligation?

Yes No

  1. Do you have a significant financial interest or serve as a director or officer in a commercial organization that is directly related to your research interest (or is affected by your research) or directly relates to a business decision you are participating in involving University funds? For this purpose "Significant Financial Interest" (SFI) means 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); and intellectual property rights (e.g., patents, copyrights and royalties from such rights). The term SFI does NOT include:

(1)salary, royalties, or other remuneration from the institution (Note: royalties paid to an investigator on behalf of Utah State University are not considered reportable SFIs);

(2)income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities;

(3)income from service on advisory committees or review panels for public or nonprofit entities; or

(4)an equity interest that when aggregated for you meets both the following tests: is less than $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and is less than a five percent ownership interest in any single entity; or

(5)salary, royalties or other payments that when aggregated for you over the next twelve months, are not expected to exceed $10,000.

Yes No

  1. InUSU courses you teach or for which you have direct responsibility, do you require the use of a textbook or course materials which you have authored or compiled and from which, based on USU sales only, you receive a royalty or other sales proceeds in excess of $500 annually?

Yes No

  1. Do you use or propose to use University facilities or personnel to conduct research, testing, or work for your outside interests excluding University-administered sponsored projects? (For purposes of this assurance, the incidentaluse of university facilities such as, for example, the occasional use of telephones for your non-university interests or the use of offices or practice rooms for the teaching of music students is allowed. You may check "no" if your only non-university use of university facilities is of an incidental nature.)

Yes______No______

  1. Do you consult, otherwise work for, or have a significant financial interest in any commercial funding source that also sponsors research at the University for which you have responsibility for designing, conducting or reporting of the research, or with which you are otherwise involved?

Yes______No______

  1. Have you, or has your program, received gifts of $100 or more (cumulative over the year) from any commercial entity in which you have a significant financial interest, or whose business is directly related to your research interest?

Yes No

  1. Do you supervise students or post-doctoral fellows in any research effort that is directly related to your outside financial interests (e.g., external consulting, intellectual property development, equity or stock options, or sponsored project that you are doing for a commercial purpose)?

Yes No

  1. Are there any non-faculty staff on your project, including students and technicians, who are funded by a commercial sponsor in which either you or they have a significant financial interest and who are also responsible for the design, conduct, or reporting of research activities?

Yes No

9(a). Please provide the names of any personnel for whom you answered yes on question 8, above.

Assurance Options

  1. IF YOU ANSWERED "NO" TOALL QUESTIONS, SIGN HERE AND RETURN THIS FORM TO YOUR DEPARTMENT OFFICE.

Signature:______

Printed Name: ______

Email Address: ______

Department/Division:______

Date:______

NOTE: If your answer to any of the above questions changes during the next year,you are responsible for modifying your assurance of compliance and submitting the necessary Disclosure of Information (Form 2).

  1. IF YOU ANSWERED "YES" TO ONE OR MORE QUESTIONS, SIGN BELOW, RETURN THIS FORM TO YOUR DEPARTMENT OFFICE. THEY, IN TURN, WILL FORWARD IT TO THE OFFICE OF COMPLIANCE ASSISTANCE, AND YOU WILL RECEIVE A DISCLOSURE OF INFORMATION FORM (FORM 2) REQUESTING FURTHERINFORMATION.

Signature:______

Printed Name: ______

Email Address: ______

Department/Division: ______

Date: ______