Office of Research Integrity

Vice President for Research

2420 Lincoln Way, Suite 202

Ames, Iowa 50014-8340

515 294-3324

PHS Financial Disclosure Form for Investigators from subrecipient entities that do not have a PHS-compliant conflict of interest policy in effect at time of PHS award application

In accordance with the Iowa State University Conflicts of Interest and Commitment Policy and Management of Conflicts of Interest Related to Public Health Services Sponsored Awards for Research (42 C.F. Part 50, Subpart F and 45 C.F.R., Part 94), investigators from a subrecipient entity that does not have a PHS-compliant policy in effect at the time of PHS award application must disclose their personal significant financial interests (and those of their spouse/registered domestic partner and/or dependent children). This includes the Principal Investigator, Co-Investigators, Senior and Key Personnel, and any other individual who is responsible for the design, conduct, or reporting of research funded by PHS or an agency or organization that follows PHS disclosure requirements (for example, American Heart Association, American Cancer Society, etc.). See more information.

  1. Research Identifying Information

Proposal Title:

Sponsoring Agency:

Iowa State University Principal Investigator:

  1. Disclosing Investigator Contact Information

Name:

Address:

Phone:

Email:

Employer Name:

  1. Financial Interest Questions

Below, you will be asked questions intended to identify Significant Financial Interests and relationships that may be relevant to this research. In relation to this research, for the past 12 months, have you, your spouse or domestic partner, and/or dependent children had or do you/they anticipate having any of the following Significant Financial Interests:

  1. An equity interest in any publicly or privately owned entity whose financial interests could be affected by this research, including but not limited to shares of stock or stock options? Do not include equity held in a mutual, pension, or investment fund over which you have no control with regard to investment decisions.

Yes No

If yes, identify -

Entity Name / Publicly Traded or Privately Owned? / Type of Equity (Stock, Stock Option, Other) / If Stock: / If Options, Estimated # held
% Equity Owned / Estimated Amount
  1. An inventorship or ownership interest in any intellectual property being tested, evaluated, developed in, or its commercial value will be affected by this research? This includes intellectual property that is the subject of a copyright, issued patent or patent application regardless of whether it has been licensed or optioned.

Yes No

If yes, provide –

Description of IP / Entity that owns IP / Licensed/ Optioned? / $ Amount royalties or compensation w/in past 12 months
(Y/N)
If yes, name of entity
  1. Any payments exceeding $5,000, in the past 12 months (excluding payments from your institution receiving the subcontract from Iowa State University), including salary, honoraria, fees, or other forms of compensation or anything of value from any entity having a financial interest in this research?

Yes No

Entity Name / Type of activity / Ongoing? (Y/N) / $ Amount w/in past 12 months
  1. Travel Reimbursement/Sponsorship

Have you received any travel reimbursement or been sponsored for travel (i.e. travel expenses paid on behalf of Investigator and not reimbursed to Investigator), in the past 12 months, by any entity related to your institutional responsibilities? This does not include travel sponsored or reimbursed by a federal, state, or local government agency, a US institution of higher education or an affiliated research institute, an academic teaching hospital, or a medical center.

Yes No

Travel Sponsor / Travel Purpose / Destination / Total # Days

Acknowledgment and Certification

I certify that the above information is complete and true to the best of my knowledge. I also acknowledge that by signing my name below that it is my responsibility to disclose, within 30 days, any new significant financial interests obtained during the term of the above proposed project.

Signature of Investigator: Date:

Printed Name:

Subrecipient Institution: