Georgia Tech

Conflict of Interest Management Plan for STTR Awards

FACULTY MEMBER:

Faculty Member/PI:
School, Department, or Center:

COMPANY SPONSOR:

Name of Company Sponsor:
If this is a start-up company, what is your role, if any, in the founding of the new company and what is/your continuing involvement?
What is the intellectual property on which the company is based?
Describe the research capabilities of the company, including a description and location of facilities.

SIGNIFICANT FINANCIAL INTERESTS

Regarding this company, do you, your spouse or dependent children: / Yes / No
a. Own any shares of stock, stock options, partnership interest, or other ownership interest if the company is
NOT publicly traded?
b. Own any shares of stock, stock options, partnership interest, or other ownership interest which is either greater than 5% of the company or greater than $10,000 in value, if the company IS publicly traded?
c. Receive or expect to receive $10,000 in aggregate in compensation for consulting or employment from the company? company?
d. Serve as Management (i.e. CEO, CFO, CIO, CTO, secretary, treasurer or on the Board of Directors of the company?
e. Serve as a Scientific Advisor or in a technical role in the company?
f. Serve on an Advisory Board of the company?
g. Have an interest in a patent, copyright or licensing agreement that may be affected in terms of value by this
research?
h. Have assigned an interest in any invention, patent application, etc. that is to an outside entity?
i. Receive or expect to receive greater than $10,000 in personal income directly from this company for licensing intellectual property of any type (including honoraria or royalties for book, publications, or lectures)?
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k. Do other faculty members have any ownership interest in the company?
If yes, who?
l. Does you supervise these individuals in his/her capacity as a member of the Georgia Tech Faculty or serve
on a tenure and promotion committee?
m. Will graduate or undergraduate students or postdocs work for the company?
n. If yes, are these students expected to be enrolled in a course taught by the Faculty Member?
o. Will the Faculty Member serve as a thesis advisor or graduate committee member for the students?

INTELLECTUAL PROPERTY OWNERSHIP

Is the company sponsor a licensee of GTRC-owned intellectual property?Yes No

If yes, list the inventors of the licensed technology and GTRC ID, if known:

MANAGEMENT OF THE SPONSORED AWARD

Will the company issue a subcontract to GTRC?Yes No

Federal/prime award to company:

Which federal agency issued the STTR award to the company?

Who will serve as PI on the company’s federal award?

Is he/she also a Georgia Tech employee? Yes No

If yes, what is the level of effort* of the PI while working for the company?

If yes, what is the level of effort* of the PI with Georgia Tech?

* Level of effort means percent of Georgia Tech appointment.

Subcontract to GTRC:

Who will serve as PI on the subcontract awarded to GTRC?

Who will control the design, conduct, and reporting of the research defined by the subcontract scope of work?

To whom does the PI on the subcontract report?

What Georgia Tech facilities and equipment, will be used in the performance of the subcontract?

Will graduate or undergraduate students or postdocs be involved in this subcontract research? Yes No

OVERSIGHT

Will an oversight committee be appointed to review project design, conduct and reporting? Yes No

If yes,

Who will serve on the committee?

Who will chair the committee?

How often will the chair submit reports to Georgia Tech’s Conflict of Interest Committee?

MANAGEMENT PLAN:

At a minimum, the restrictions identified below will apply to all COI Management Plans, but the Georgia Tech COI Committee may impose additional restrictions, including the requirement that all intellectual property developed as part of the described project, which may be owned by the university or the company, be disclosed to both parties to ensure ownership matters are addressed appropriately.

  • The PI may not serve on the company’s board of directors.
  • If the PI wishes to continue serving as the PI for any research project supported by the company and the PI has a direct management role in the company, a plan shall be developed with the Georgia Tech COI Committee and approved by the Vice Provost for Research for the Investigator’s transition out of the management role as soon as is practicable.
  • The PI may participate on the company’s scientific advisory board, but will recuse him/herself from decisions by the scientific advisory board, which involve his/her research.
  • Use of university facilities or services must be in compliance with all relevant university policies pertaining to use by external parties.
  • The relationship with the company may not restrict publications or presentations.
  • Generally, students may not be involved in the research while they are concurrently supervised by the PI or enrolled in the PI’s courses.
  • The PI will continue to complete and submit to his supervisor an annual COI disclosure form.
  • The PI will submit an updated COI disclosure form to his supervisor if there is any change in his/her activities or financial interests that would affect or be affected by the outcome of this research project.
  • The PI will submit an annual report due July 1 to the Georgia Tech COI Committee reviewing any changes to the information contained herein.

Additional Actions to be taken in management plan:

CERTIFICATION AND SIGNATURE OF FACULTY MEMBER

I certify that the above information is complete and true to the best of my knowledge and that I have read the University’s policies related to conflict of interest as described in the Georgia Tech Faculty Handbook Section 38, Conflict of Interest, Consulting, and Disclosure, and the corresponding Georgia Tech Report on Outside Professional Activity and Potential Conflict of Interest.

I acknowledge my obligation to submit an updated COI disclosure form at least annually or when there is any change in my activities or financial interests that would affect or be affected by the outcome of this research project.

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Signature of InvestigatorDate

Reviewed by:

______

Chair or DirectorDateDeanDate

Approved by:

______

Member of the Georgia Tech COI CommitteeDate