NIHFinancial Interest Disclosure: Form B
Please complete and sign this form if you answered “yes” to any question on Form A.
Printed Name of Investigator:
Proposal #:
SECTION I – PUBLICLY TRADED ENTITIES (Check here if section N/A: go to next section)
Make multiple entries in the table below for separate companies or if there are multiple types of remuneration or equity for one company.
The CSU, Chico Research FoundationPage 1
revised 11/2016
Are there students or post-docs involved who are either funded by one of these companies in which you have an interest or are participating in research funded by one of these companies?
YesNo If “yes,” please explain:
Do you have any current or pending grants, contracts, institutionally sponsored research or human subject protocols that are or appear to be related to the financial interest you disclosed above?
Yes No If “yes,” please explain:
Please provide any additional information you believe would be helpful in understanding these financial interests, including any paid or unpaid positions at each company (Attach additional pages if necessary):
SECTION II – NON-PUBLICLY TRADED ENTITIES
(Check here if section N/A: go to next section)
Make multiple entries in the table below for separate companies or if there are multiple types of remuneration or equity for one company.
The CSU, Chico Research FoundationPage 1
revised 11/2016
The CSU, Chico Research FoundationPage 1
revised 11/2016
Are there students or post-docs involved who are either funded by one of these companies in which you have an interest or are conducting research funded by one of these companies?
Yes No
Do you have any current or pending grants, contracts, institutionally sponsored research or human subject protocols that are or appear to be related to the financial interest you disclosed above?
Yes NoIf “yes,” please explain:
Please provide any additional information you believe would be helpful in understanding these financial interests, including any paid or unpaid positions at each company (Attach additional pages if necessary):
SECTION III – INTELLECTUAL PROPERTY (Check here if section N/A)
Make multiple entries in the table below for separate companies or if there are multiple types of remuneration or equity for one company.
The CSU, Chico Research FoundationPage 1
revised 11/2016
The CSU, Chico Research FoundationPage 1
revised 11/2016
Do you have any current or pending grants, contracts, institutionally sponsored research or human subject protocols that are or appear to be related to the financial interest you disclosed above?
Yes No If “yes,” please explain:
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 and procedures related to conflict of interest available at http://www.csuchico.edu/resp/formspoltravel/index.shtml. Appropriate Institutional Officials will review this information in confidence. By signing below, the investigator acknowledges that the information may be disclosed to persons and entities, including but not limited to, the Vice Provost for Research, University personnel, NIH personnel, state and federal oversight agencies, as necessary to comply with the terms of grants/contracts or other agreements related to this proposal and to determine and ensure compliance with applicable laws including the Richard McKee Transparency Act of 2011, regulations, policies and procedures.
I acknowledge my obligation to submit an updated form when there is a change in my activities or financial interests related to my institutional responsibilities.
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SignatureDate
The CSU, Chico Research FoundationPage 1
revised 11/2016