This (1) Financial Disclosure and (2) Debarment and Suspension Form Is to Be Used For

This (1) Financial Disclosure and (2) Debarment and Suspension Form Is to Be Used For

This (1) Financial Disclosure and (2) Debarment and Suspension Form is to be used for non-Public Health Services proposals.

CENTRAL MICHIGAN UNIVERSITY

PROJECT BY PROJECT

CONFLICT OF INTEREST FINANCIAL DISCLOSURE AND DEBARMENT AND SUSPENSION STATEMENT REGARDING SPONSORED PROJECTS

To Be Completed by Each Investigator

I understand that I must log into Cayuse using my CMU global ID and approve submission of this proposal. My electronic approval in the Cayuse system certifies that I have read and agree to comply with the Central Michigan University Conflict of Interest Guidelines - Section XI Sponsored Projects and attest to the disclosure below. In addition, I understand that it is my responsibility to inform the Office of Research and Graduate Studies (ORGS) if I have a new reportable significant financial interest related to this project after the submission of this form.

DATE COMPLETING FORM:

NAME:

DEPARTMENT:

TITLE OF SPONSORED PROJECT:

NAME OF FUNDING SPONSOR:

PROJECT PERIOD: / / to / /

Financial Disclosure

*Family/Household is defined to include a) Family/Household (spouse, parents, and children) and b) persons living at the same residence as the faculty/staff member, except their tenants or employees.

1. Are you or any member of your Family/Household an officer, director, trustee, sole proprietor, partner, employee, sales representative, agent, consultant, independent contractor, or advisory board member of either the external organization/agency funding this sponsored project or an external organization/agency from which goods and services could be obtained under this sponsored project?

NO YES

2. Do you and other members of your Family/Household own stock which has an aggregate value of more than $10,000 or which represents more than five percent (5%) of the voting stock in the external organization/agency funding this sponsored project or any external organization/agency from which goods and services could be obtained under this sponsored project?

NO YES

3. Did you and/or other members of your Family/Household derive aggregated income within the past year, or do you or any member of your Family/Household anticipate deriving aggregated income, exceeding $10,000 per year from the external organization/agency funding this sponsored project or any external organization/agency from which goods and services could be obtained under a sponsored project?

NO YES

*Note: Positive financial disclosures must be accompanied with a Financial Disclosure Statement Explanation Form, which can be found at http://www.purchasing.cmich.edu/COI/attachBpart2.html

Debarment and Suspension:

In addition, I certify to the following:

  • that I have not been debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any federal department or agency;
  • that within a 3-year period preceding this proposal, I have not been convicted of or had a civil judgment rendered against me for commission of fraud or a criminal offense in connections with obtaining, attempting to obtain or performing a public transaction or contract under a public transaction; violation of federal or state antitrust statues or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property;
  • I am not presently indicted or otherwise criminally or civilly charged by a government entity (federal, state, or local) with commission of any of the offenses enumerated above;
  • I have not, within a 3-year period preceding this application, had one or more public transactions (federal state, or local) terminated for cause or default.

I certify to the above debarment and suspension criteria.

NO YES

Revised 8/14/2017