Michigan State University s5

Conflict of Interest (COI) Disclosure Form

For a Project Involving Human Subjects

Michigan State University’s Institutional Review Boards (IRBs)

Biomedical & Health Institutional Review Board (BIRB)

Community Research Institutional Review Board (CRIRB)

Social Science / Behavioral / Education Institutional Review Board (SIRB)

IRB Contact Information

Phone: (517) 355-2180 Fax: (517) 432-4503 Email: Office Hours: Mon– Fri (8AM – 5PM)

Address: Michigan State University / Olds Hall / 408 West Circle Dr., Rm. 207 / East Lansing, MI 48824

DIRECTIONS: All individuals responsible for the design, conduct, or reporting of findings for the research project, including research staff, must complete all questions and attach with the initial application or upon addition to an ongoing research project for full board research projects. For more information, see HRPP Manual Section 10-1 Conflict of Interest on human research website, www.humanresearch.msu.edu
Your Name: / IRB# or Application #: / Today’s Date:
Research Project Title:

Objectivity is a key component of any research project. One method for maintaining objectivity is to have all those involved in the research (design, conduct, or reporting of findings) disclose potential and/or real financial conflict of interest, or other opportunity for tangible personal benefit related to the research, that might compromise, or reasonably appear to compromise, the independence of judgment with which their responsibilities would be completed under this research.

1. Please indicate whether you, or a member of your immediate family1, have any significant financial interests2 that relate to or could be affected by the outcomes of this research project. A reportable financial interest includes, but is not limited to, a financial interest in the sponsor, product, or service being tested, or in a competitor of the sponsor or product or service being tested. Complete i if you answer “Yes” to any of the scenarios below.

A. / Salary, consulting fees, royalties or other payments of any kind from a single entity which exceeded $10,000 over the last 12 months or which are expected to exceed $10,000 over the next 12 months / No / Yes
B. / Ownership interests in a single entity which have a fair market value of more than $10,000 or are more than one percent (1%) of its equity / No / Yes
C. / Intellectual property rights which have a fair market value of over $10,000 or which generate, or are expected to generate, revenues of over $10,000 per year / No / Yes
D. / Unvalued stock options or other options for ownership in a privately held company / No / Yes
E. / Paid or unpaid service on a governing or advisory board, or in a fiduciary or managerial role, for, or as a general partner of, an entity / No / Yes
F. / Serving as a trustee for a trust or estate, or having a beneficial interest in a trust or estate, whose value exceeds $10,000 / No / Yes
G. / Indebtedness to or from a single entity exceeding $10,000 / No / Yes
H. / Receipt of gifts of goods, property, or services, like airline tickets, resort or hotel accommodations, or other recreational or personal amenities whose value exceeds $250 from a single entity / No / Yes
I. / Any other opportunity for tangible personal benefit related to the conduct of the research that might compromise, or reasonably appear to compromise, the independence of judgment with which their responsibilities would be completed under this research protocol / No / Yes
1 Immediate family is defined as a spouse or domestic partner, dependent children, and any other dependents who reside with you. This will usually be a smaller group of people than your relatives.
2 The following financial interests are excluded from consideration and do not need to be reported
· Salary or other remuneration from the University or paid at the University's behest (including remuneration from a University-approved practice plan),
· Income from seminars, lectures, service on committees or review panels, or other educational activities sponsored by public or not-for-profit entities,
· Any financial interest arising solely by means of investment in a mutual, pension, or other institutional investment fund over whose management and investments neither the faculty member nor any immediate family member of the faculty member exercises control (e.g., TIAA-CREF), and
· Indebtedness from a bank, credit union, or other commercial lender

i. Describe the details of the conflict situation (complete only if you answered “Yes” to any of the scenarios in Question 1).

2. No Yes Has any financial arrangement, including compensation, ownership interest, stock options, or other ownership interest, (e.g., compensation that is: explicitly greater for a favorable result; in the form of an equity interest in the sponsor of a covered study; or in the form of compensation tied to sales of the product, such as a royalty interest) been established whereby the value of compensation or ownership interest to investigators conducting the study could be influenced by the outcome of the study? If yes, complete A.

A. Describe the details of the financial arrangement and the basis for possible changes in the value of the compensation.

The information reported is true and complete to the best of my knowledge. If there are any corrections or changes, I will promptly notify the IRB.
SIGN HERE: / DATE:

Last Updated: 10/25/2012

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