Conflicts of Interest Disclosure Form

EXPANDED CONFLICTS OF INTERESTS DISCLOSURE FORM

UNIVERSITY OF OKLAHOMAHEALTHSCIENCESCENTER

This form must be completed if the Principal Investigator/Employee answered YES to any questions on Part II of the Conflicts of Interest Disclosure Form or as otherwise required by the Conflicts of Interest Policy.

See:

PERSONAL IDENTIFICATION

NameTitle

CollegeDepartment/Section

E-mailPhone

TYPE(S) OF DISCLOSURE (CHECK ALL THAT APPLY)

New sponsored activity (research, training, or public service)

New professional service (PPP) activity (consulting, speaking, training, etc.)

Additional activity/relationship with a Sponsor/Company

New Conflict of Interest relating to a previously disclosed activity

Date of previous disclosure:

Other:

SPONSOR/COMPANY INFORMATION (if applicable)

1. Type:FederalStateIndustryNon-Profit n/a

2. Sponsor/Company is: Privately Held Publicly Traded Government Other

3. Name and address of Sponsor/Company:

ACTIVITY/RELATIONSHIP INFORMATION

1. Type of activity/relationship:

Consulting Gift Operating Officer Speaker

Board Member Grant Research Training

Director MTA Scientific OfficerOther

2. Title of this activity/relationship, if applicable:

3. Description of this activity/relationship:

4. Are students and/or post-doctoral fellows involved in the activity/relationship? Yes No

If yes, describe the role they will play and any possible limitations on their ability to publish and/or progress in their program. The signature of the Dean of the GraduateCollege must be obtained if students and/or post-doctoral fellows are involved.

5. Consideration to Principal Investigator/Employee (check all that apply):

Honorarium/Consulting FeesSalaryRoyalties

Stock (including options as payment) DividendsGoods or services

Gifts Other (specify)

6. Consideration to spouse/domestic partner, and/or child (check all that apply):

Honorarium/Consulting FeesSalaryRoyalties

Stock (including options as payment) DividendsGoods or services

Gifts Other (specify)

7. Indicate any other activity/relationship you have with this Sponsor/Company.

Consulting Gift Operating Officer Speaker

Board Member Grant Research Training

Director MTA Scientific OfficerOther

a. Describe the other activity/relationship and/or position identified above:

b. Consideration to Principal Investigator/Employee for the other activity/relationship (check all that apply):

Honorarium/Consulting FeeSalaryRoyalties

Stock (including options as payment) DividendsGoods or services

GiftsOther (specify]

c. Consideration to spouse/domestic partner, and/or dependent child (check all that apply):

Honorarium/Consulting FeeSalaryRoyalties

Stock (including options as payment) DividendsGoods or services

GiftsOther (specify)

INTELLECTUAL PROPERTY

YesNo

Have you submitted an Invention Disclosure form to the Intellectual Property Management Office/Office of Technology Development relating to this disclosed activity?

Has the University licensed intellectual property derived from any of your work at the University to the Sponsor/Company or to any entity involved in this disclosed activity?

Does/Will the Sponsor/Company or any other entity involved in this disclosed activity have any rights to intellectual property produced, discovered, or created, in whole or in part, by you?

HUMAN RESEARCH PARTICIPANTS

YesNo

Are human research participants involved in this research project?

If Yes, attach the complete University of Oklahoma HRPP Conflict of Interest Disclosure Form to Institutional Review Board form, the HRPP determination letter, your protocol, and the IRB-approved informed consent form.

TO COMPLETE THIS DISCLOSURE, GO TO SIGNATURE PAGE 4. OBTAIN ALL REQUIRED SIGNATURES PRIOR TO FORWARDING COMPLETED DISCLOSURE TO THE VICE PRESIDENT FOR RESEARCH.

REQUIRED SIGNATURES

Principal Investigator/Employee

Signature:______Date:______

Department Chair

Name:

Comments:______

______

Approved as disclosed

Approved with attached Management Plan

Activity/relationship not approved

Signature:______Date:______

College Dean

Name:

Comments: ______

______

Approved as disclosed

Approved with attached Management Plan

Activity/relationship not approved

Signature:______Date:______

Dean of the GraduateCollege Signature (required if students/post docs involved):

Name:

Comments: ______

______

Approved as disclosed

Approved with attached Management Plan

Activity/relationship not approved

Signature:______Date:______

Vice President for Research

Name:

Comments: ______

______

Approved as disclosed

Approved with attached Management Plan

Activity/relationship not approved

Signature:______Date:______