This (1) Financial Disclosure and (2) Debarment and Suspension Form is to be used for non-Public Health Services proposals.

CENTRAL MICHIGAN UNIVERSITY

PROJECT BY PROJECT

CONFLICT OF INTEREST FINANCIAL DISCLOSURE AND DEBARMENT AND SUSPENSION STATEMENT REGARDING SPONSORED PROJECTS

To Be Completed by Each Investigator

I understand that I must log into Cayuse using my CMU global ID and approve submission of this proposal. My electronic approval in the Cayuse system certifies that I have read and agree to comply with the Central Michigan University Conflict of Interest Guidelines - Section XI Sponsored Projects and attest to the disclosure below. In addition, I understand that it is my responsibility to inform the Office of Research and Graduate Studies (ORGS) if I have a new reportable significant financial interest related to this project after the submission of this form.

DATE COMPLETING FORM:

NAME:

DEPARTMENT:

TITLE OF SPONSORED PROJECT:

NAME OF FUNDING SPONSOR:

PROJECT PERIOD: / / to / /

Financial Disclosure

*Family/Household is defined to include a) Family/Household (spouse, parents, and children) and b) persons living at the same residence as the faculty/staff member, except their tenants or employees.

1. Are you or any member of your Family/Household an officer, director, trustee, sole proprietor, partner, employee, sales representative, agent, consultant, independent contractor, or advisory board member of either the external organization/agency funding this sponsored project or an external organization/agency from which goods and services could be obtained under this sponsored project?

NO YES

2. Do you and other members of your Family/Household own stock which has an aggregate value of more than $10,000 or which represents more than five percent (5%) of the voting stock in the external organization/agency funding this sponsored project or any external organization/agency from which goods and services could be obtained under this sponsored project?

NO YES

3. Did you and/or other members of your Family/Household derive aggregated income within the past year, or do you or any member of your Family/Household anticipate deriving aggregated income, exceeding $10,000 per year from the external organization/agency funding this sponsored project or any external organization/agency from which goods and services could be obtained under a sponsored project?

NO YES

*Note: Positive financial disclosures must be accompanied with a Financial Disclosure Statement Explanation Form, which can be found at http://www.purchasing.cmich.edu/COI/attachBpart2.html

Debarment and Suspension:

In addition, I certify to the following:

  • that I have not been debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any federal department or agency;
  • that within a 3-year period preceding this proposal, I have not been convicted of or had a civil judgment rendered against me for commission of fraud or a criminal offense in connections with obtaining, attempting to obtain or performing a public transaction or contract under a public transaction; violation of federal or state antitrust statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;
  • I am not presently indicted or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated above;
  • I have not, within a 3-year period preceding this application, had one or more public transactions (federal state, or local) terminated for cause or default.

I certify to the above debarment and suspension criteria.

NO YES

Revised 8/14/2017