DRAFT Conflict of Interest Screening/Disclosure Form-1999-2000

This form must be submitted with every Sponsored and Unsponsored Protocol/Proposalto assess potential financial conflict of interest.

All employees, students, collaborators or volunteers involved in the design, conduct, or reporting of this protocol/proposal must complete this form.

Name: Protocol/Proposal Sponsor:

E-mail: Protocol/Proposal Title:

If applicable, please enter the Protocol/ProposalAccount #: and/or IRB #:

Part I – Financial Disclosure

Yes NoHave you or a member of your immediate family as defined in the Financial Conflict of Interest for Sponsored Programs Policy #3364-70-01 received or anticipate receiving, within the next twelve months, personal income from a company or organization whose activities could possibly relate in any way to your proposed research? Personal income includes: consulting; speaking or other fees; honoraria; gifts; licensing revenues (royalty income); equity interests (including stocks, stock options, warrants, partnership and other equitable ownership interests)AND/OR do you or a member of your family as defined above serve on a board of the company or organization? IF NO, GO TO PART II on page 2

Yes NoIn aggregate, is the total financial relationship with this company $10,000?

IF NO, GO TO PART II on page 2

If you answered YES to both of the above questions:

a. Please list the company(s) or organization(s) if different from Proposal Sponsor:

b. Indicate your current or anticipated financial interest/income by answering each item Yes or No. For each item answered Yes, mark the appropriate dollar amount or estimated value:

Please continue to page 2 of this form.

Part II -Affirmation and Assessment

In submitting this form, I affirm that the above information is true and complete to the best of my knowledge; I accept responsibility for complying with the University policy on Financial Conflict of Interest and I assume responsibility for updating this disclosure as necessary. “Per” signatures will not be accepted.

Signature:Date:

Ifany of the answers to Part I wereYES,please request the signature of your department Chairperson or equivalent supervisory official on the line below.

Signature:Date:

IMPORTANT SUBMISSION INSTRUCTIONS:

ForUNSPONSORED Protocols/Proposals

Please forward all original disclosures to the appropriate Institutional Review Board office as part of your submission packet:

For SPONSORED Protocols/Proposals

Please forward all original disclosures to the appropriate Research and Sponsored Programs Office and copies to the appropriate IRB office.

Please visit the Conflict of Interest website athttp://www.utoledo.edu/research/RC/COI.html for links to relevant policies and forms.

Version date: 01.2009Financial Disclosure Form - RSP 102 Page 1 of 2