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Conflict of Interest Disclosure

This Financial Disclosure Form must be completed by the external investigator requesting UIRB review and approval of human subject research. All financial interests relating to the research must be disclosed for review by UIRB. University of Utah personnel should NOT use this form.

  • What is the purpose of your COI Disclosure?

    This Financial Disclosure Form must be completed by the external investigator requesting UIRB review and approval of human subject research.  All financial interests relating to the research must be disclosed for review by UIRB.

    All individuals responsible for the design, conduct, or reporting of findings for the research project, including research staff, must complete all questions and return to the PI/study team of the applicable research
    project prior to your engagement in research activities.

    Your COI Disclosure Form is the primary tool used by the University of Utah to help ensure compliance for the following policies and regulations:

    For more information, see the University of Utah’s policies on Conflict of Interest found here: https://coi.utah.edu/.

  • Financial conflicts of interest exist when your personal financial interests have the potential to influence your University responsibilities in one or more of these areas:

    • research
    • business transactions (e.g., license agreements, subcontracts, other contracts)
    • intellectual property

    The University encourages relationships with the business community. In situations where these relationships create financial conflicts of interest, the University must promptly identify them and ensure that they are appropriately managed, reduced or eliminated to protect the individual and the institution.

    The influence of your personal financial interests on your University responsibilities may be unintentional or even subconscious. Therefore, an independent evaluation of your personal financial interests is important to prevent any negative consequences for you or the University. Potential negative consequences, real or perceived, may include:

    • bias in research or academic work
    • improper influence over University subordinates or students
    • undue influence on research participants
    • inappropriate uses of University funds or property
    • public allegations of unethical behavior

    These situations can impair the integrity of the research enterprise and have the potential to damage the reputations of the individual and the University.

    Terms to Understand: For definitions of terms like "immediate family" and "financial relationship", please visit: https://regulations.utah.edu/general/1-006.php.  Please visit https://coi.utah.edu/training-and-faq.php for more information.

**If any of the following are true for the individual listed below or any member of the individual’s immediate family further information will be requested.

Are any of the following statements true for you or your immediate family?

  • Has employment outside of your institution (e.g. University of Utah) that reasonably appear to be related to your professional responsibilities? (Individuals completing this disclosure who are not employees of the University of Utah should report employment that reasonably appears to be related to their responsibility to their employer or profession.)
  • Has any other Financial Relationship that reasonably appear to be related to your professional responsibilities to your institution (e.g. University of Utah), as defined by your department or job description? Unpaid leadership positions are included in the definition of Financial Relationships and should be reported here. (Individuals completing this disclosure who are not employees of the University of Utah should report employment that reasonably appears to be related to their responsibility to their employer or profession.)
  • Conducts research or participate in any other sponsored activities at your institution (e.g. Principal Investigator, Sub-Investigator, Project Director, Post Doc/student performing research, etc.)?
  • Has Intellectual Property (external to the University) that is reasonably related to your professional responsibilities to the University?
  • Has traveled or had related expenses paid or reimbursed by a Foreign-based Entity and/or Foreign-based Person?
  • Has a financial interest in the research with value that cannot be readily determined (for example, stock that is not publicly traded);
  • Has a financial interest in the research with value that exceeds $5,000 other than payments for conducting the trial as outlined in the clinical trials agreement;
  • Has a financial interest in the research with value that exceeds 5% ownership;
  • Has received or will receive compensation with value that may be affected by the outcome of the study;
  • Has a proprietary interest in the research, such as a patent, trademark, copyright, or licensing agreement;
  • Has received or will receive payments other than payment for the conduct of clinical research from the sponsor that exceeds $5,000 in the last 365 days;
  • Is an employee of the agency or company sponsoring the research;
  • Is on the board of directors of the sponsor;
  • Has a financial interest that requires disclosure to the sponsor or funding source;
  • Has any other financial interest that the investigator believes may interfere with his or her ability to protect subjects; or
  • Is affiliated with an institution with a lower conflict of interest threshold than the amounts referenced above.
COI Disclosure - External Investigator
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My answer is "No" for each of the items listed above.
Disclosure Certification