SignificantFinancialInterests(SFI) Initial Disclosure Form

To be completed when submitting proposals to federal funding agencies

Directions: This form must be completed by all individuals listed on the proposal and submitted to Research Integrity and Compliance (RIC) before the proposal is submitted to Sponsored Programs Administration (SPA) for transmittal.

For faster processing, please submit to RIC via email to

Investigator:Dept:College/Unit:

Project PI: ______Investigator email:

Part I: Investigatoracknowledgement of policy and requirements:

NDSU policy related to Financial Conflict of Interest (FCOI) is Policy 823. For a quick review of the federal requirements, including definitions of key terms, please review the information on the RIC website:

Part II: Questions

  1. Other than your salary from your primary employer, do you (or your spouse, domestic partner, or dependent children) have a “significant financial interest” as defined in the policy (see page 2 of this form), in an outside entity that is related to your professional expertise or NDSU responsibilities, or related to a business decision you are participating in involving NDSU funds?

Yes – If funded, you will need to submit additional information to determine if a management plan is necessary. We recommend that you begin this process as soon as possible as it may take months to obtain agreement and approval. Funds will not be disbursed until the plan has been reviewed and approved.

No

  1. Do you propose to use NDSU facilities or personnel to conduct research or testing for any outside interest that is not administered through the University?

Yes -- If funded, you will need to submit additional information to determine if a management plan is necessary. We recommend that you begin this process as soon as possible as it may take months to obtain agreement and approval. Funds will not be disbursed until the plan has been reviewed and approved.

No

Part III: Assurance Statement

Bysigningbelow, I confirm that I have read and will abide by the NDSU FCOI policy and provideassurance that the information provided is true to the best of my knowledge.

InvestigatorSignature______Date______

SFI includes anything of monetary value whether or not the value is readily ascertainable, that reasonably appears to be related to your institutional responsibilities: including, but not limited to:

  • Payments for services (eg. Consulting fees, lecture payments, paid authorship or honoraria)
  • Equity interests (eg. Stocks, stock options, or other ownership interests)
  • Intellectual property rights and interests (eg. Patents, copyrights, and royalties from such rights)

SFI does NOT include:

  • Ownership of shares in a mutual fund
  • Salary or other remuneration received from NDSU
  • Income from seminars, lectures, or teaching engagements sponsored by Federal, state, or local government agency, a US institution of higher education, an academic teaching hospital, medical center, or a research institute that is affiliated with a US institution of higher education.
  • Income from service on advisory committees or review panels for federal, state, or local government agency, a US institution of higher education, academic teaching hospital, medical center or research institute that is affiliated with a US institution of higher education
  • Payments made to NDSU by an outside organization
  • Income from investment vehicles, such as mutual funds and retirement accounts, as long as the individual does not directly control the investment decisions in these vehicles.

What are the next steps?

If your proposal is successful, there are a number of things to do nowto avoid delay in receiving funds.

  1. All investigatorsneed to complete the “Conflict of Interest” training available on the CITI website This training will need to be repeated every four (4) years.
  2. “Responsible Conduct of Research” (RCR) training is required and may be fulfilled by the CITI program or by participation in department sponsored RCR training sessions.
  3. If you indicated “YES” to 1. or 2. (above) you should submit additional information about the SFI to the Research Integrity & Compliance (RIC) office so it can be determined if a management plan will be necessary if you are funded.
  4. If it is determined that ‘yes” a management plan will be necessary you may want to start working on a plan since it can take months to approve.
  5. If funded, an annual SFI disclosure form will need to be resubmitted to the RIC office every January, regardless of when the award was received.