Sponsored Project Supplemental Disclosure Form
This form must be completed for each entity related to positive disclosure statements in the NAU Sponsored Project General Disclosure Form that would reasonably appear to be related to your Institutional Responsibilities and/or to be affected by any sponsored project in which you are involved. These disclosures are required in accordance with the OVPR Policy, Conflict of Interest in Sponsored Projects; and for PHS-funded projects, as required by the Addendum to the Conflict of Interest in Sponsored Projects Policy: Promoting Objectivity in Research for which PHS Funding is Sought.
Date of Disclosure: / RetroactiveName: / Rank:
Department/Unit: / College/Unit:
NAU Proposal Number and/or Project Number for proposed or sponsored projects: ,
Name and address of entity:
Check one: Publicly traded Non-publicly traded
Income from this entity: Equity interest from this entity:
Basis for financial interest to you or your family members, defined as your spouse or domestic partner and dependent children (check all that apply):
Employee
Consultant
Equity Interest/Dividends
Honoraria
Income related to royalties on patents and copyrights
Service on Advisory or Board of Directors
Paid authorship
Ownership
Other:
The financial interest is between entity and (check all that apply): Self Spouse/Domestic Partner Dependent Children
The value of ownership in the external entity is ($): (Note: Dollar ranges are permissible ($0-$4,999; $5,000-$9,999; $10,000-$19,999; amounts between $20,000-$100,000 by increments of $20,000; amounts above $100,000 by increments of $50,000) or a statement that the interest is one whose value cannot be readily determined through reference to public prices or other reasonable measures of fair market value.)
Nature of ownership: Equity Interest Partnership Sole Proprietorship Other:
Percentage (%) of ownership:
Answer each of the following questions (use as much space as needed).
1. If you or your family member has received a consulting fee, describe the nature of the consulting activities.
2. Indicate how your activities with the entity relate to proposed or sponsored projects on which you serve as an investigator.
3. Explain how you are keeping your interests and obligations to the entity separate from your NAU activities and responsibilities.
4. Explain all arrangements that have been made with your chair and dean/director about the use of NAU space and resources.
5. Explain the role(s) that any other NAU faculty, staff, undergraduate students, graduate students, post-doctoral associates, research associates or other NAU-affiliated individuals perform for this entity. For students, explain how their work with the entity is kept separate from their academic work and whether you serve as their advisor.
6. If you are receiving income from royalties on patents and copyrights, explain the circumstances that generated this income.
7. Explain any reimbursed or sponsored travel paid by this entity.
Purpose of the trip:
Destination:
Duration:
Employee Certification
Ø In my judgment, this disclosure of significant financial interest is is not related to my Institutional Responsibilities, including PHS-funded sponsored projects.
Ø By completing this disclosure, I certify that I have read and understand the OVPR Policy: Conflict of Interest in Sponsored Projects; or if I am planning to participate in, or am participating in, PHS research funding, the Addendum to the Conflict of Interest in Sponsored Projects Policy: Promoting Objectivity in Research for which PHS Funding is Sought.
Ø The information provided in this disclosure is true and complete to the best of my knowledge.
Ø I agree to update this disclosure annually or as new reportable significant financial interests are obtained.
Ø I will cooperate in the development of a conflict management plan if determined to be necessary by the University
Ø I will comply with the conditions or restrictions imposed by the University to manage, reduce, or eliminate actual or potential conflicts of interest.