Principal Investigator Certification

All Investigators with responsibility for research design, conduct and reporting activities must engage in training on institution-specific policies and federal regulations regarding financial conflicts of interest. Also, all investigators must disclose to the institution all significant financial interests that would reasonably appear to be related to their institutional responsibilities and research activities. The Principal Investigator uses this form to provide basic project status information and to declare the names of involved investigators, initiating institutional review of the project and the conflict of interest compliance status of the named investigators. Please submit this form to one of the following sites (Office of Grants and Research Administration):

MSBI Investigators: Submit completed form to

MSSL Investigators: Submit completed forms to

MSR Investigators: Submit completed form to

All five sections of this form must be completed by the Principal Investigator and submitted at the time of proposal submission to the institution, at the time of application for human subject research to the Institutional Review Board or to the IACUC, or at others times as indicated by Institutional policy referenced below.

1. PRINCIPAL INVESTIGATOR AND PROJECT IDENTIFICATION

Principal Investigator’s Name:

Protocol/IRB Number and Title of Proposal/Project:

2. SUPPORT/SPONSOR STATUS (Check One)

A. Is there funding for this project from any non-MSBI/MSSL/MSR source?

YES No If yes: Indicate Sponsor Name:

B. Is the sponsor providing any medication or device at no cost to MSBI, MSSL or MSR?

YES No Not Applicable

C. Will MSBI, MSSL or MSR provide the sponsor with study data?

YES No Not Applicable

D. Are all study-related (non-routine) costs covered by the sponsor?

YES No Not Applicable

E. Is the sponsor using wire transfer, the lockbox mechanism or mailing payment to the institution?

YES No Not Applicable

3. ARE THERE OTHER INVESTIGATORS? (Check either A or B)

A No other individuals associated with this project bear responsibility for the design, conduct or reporting of the proposed or on-going research; or

B In addition to the Principal Investigator, the following individuals (attach additional page if needed) may be responsible for design, conduct or reporting activities.

PRINCIPAL INVESTIGATOR NAME / TRAINING (Select One)
VERIFICATION GRID TO BE
COMPLETED BY OGARA / DISCLOSURE (Select One)
VERIFICATION GRID TO BE
COMPLETED BY OGARA
CITI Conflict of Interest Training
Other / COI-SMART (MSBI ONLY)
SFI Disclosure Form
(MSSL/MSR ONLY)
LIST ALL OTHER
INVESTIGATORS BELOW / TRAINING (Select One)
VERIFICATION GRID TO BE
COMPLETED BY OGARA / DISCLOSURE (Select One)
VERIFICATION GRID TO BE
COMPLETED BY OGARA
CITI Conflict of Interest Training / COI-SMART (MSBI ONLY)
Other / SFI Disclosure Form
(MSSL/MSR ONLY)
CITI Conflict of Interest Training / COI-SMART (MSBI ONLY)
Other / SFI Disclosure Form
(MSSL/MSR ONLY)
CITI Conflict of Interest Training / COI-SMART (MSBI ONLY)
Other / SFI Disclosure Form
(MSSL/MSR ONLY)
CITI Conflict of Interest Training / COI-SMART (MSBI ONLY)
Other / SFI Disclosure Form
(MSSL/MSR ONLY)

4. Does the Principal Investigator have any Significant Financial Interests that may represent a real or potential conflict of interest with this submission?

Yes No

If YES, please provide details:

5. Based on communication with all of the individuals noted above, is the Principal Investigator aware of any significant financial interests held by co-investigators that may represent a real or potential conflict of interest with this submission?

Yes No

If YES, please provide details:

Principal Investigator’s Name: Date:

References: BIMC Policy 2032A Objectivity in Research

SLRHC Policy A1-129 Conflict of Interest in Research

FOR INSTITUTION USE ONLY: Reviewed by: Date:

USE THIS FORM TO DOCUMENT DEPARTMENTAL CERTIFICATION OF PROJECT COST STATUS

Memo

To:

Grant Manager/Office of Grants and Research Administration

From:

Principal Investigator

Date:

Re: Project Title: IRB#:

Check One:

There is no anticipated funding source for this project. All needed resources are available within the department.

This is a sponsored project. All costs are fully explained by the related agreement and budget.

This is a sponsored project. All costs are fully explained by the related agreement and budget. If this application includes cost sharing, documentation of the source and amount of cost sharing is attached.

Other: Please explain:

Principal Investigator

Acknowledged and agreed to by:

Department Chair or Chair Authorized Designee Date

Form SFIv.04152014 page 1 of 3 pages