### CONFLICT OF INTEREST STATEMENT {#conflict-of-interest-statement .unnumbered}

**FOR RESEARCH CONDUCTED AT**

### THE VA Pittsburgh Healthcare System {#the-va-pittsburgh-healthcare-system .unnumbered}

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

This document must be completed, signed and submitted by each Principal
Investigator at initial and continuing review of the study. Each member
of the research team who contributes 5% or more effort on the study must
complete this form at initial and continuing review of the study. The
information will be used only to review the proposed research project to
which it applies. This completed and signed document must accompany the
proposal to which it applies or the proposal will not be considered for
further review.

If you answer "Yes" to any of the items in section III or beyond, please
[**include a detailed description of the situation and the relationship
to the current project**. Use a separate page if necessary]{.underline}.
Failure to provide this information may delay processing of your
submission.

# General Information

## Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ {#name-_________________________________________________________________ .unnumbered}

> Title of Research Proposal:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## VA Employment Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ {#va-employment-title-____________________________________________________ .unnumbered}

##  {#section .unnumbered}

## University of Pittsburgh Employment Title: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ {#university-of-pittsburgh-employment-title-____________________________________ .unnumbered}

##  {#section-1 .unnumbered}

##  {#section-2 .unnumbered}

## PI Name (if other than above): \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ {#pi-name-if-other-than-above-_______________________________________________ .unnumbered}

##  {#section-3 .unnumbered}

## Role (check one): \[ \] Principal Investigator \[ \] Co-Investigator  {#role-check-one-principal-investigator-co-investigator .unnumbered}

## \[ \] Co-Principal Investigator \[ \] Collaborator {#co-principal-investigator-collaborator .unnumbered}

> \[ \] Coordinator \[ \] Research Staff

## Percent effort on research protocol: \_\_\_\_\_\_\_  {#percent-effort-on-research-protocol-_______ .unnumbered}

> Collaborating Organization(s)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Source of research support (if
applicable)\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Patents

> A. Do you or your spouse, parent, child, general partner, or an
> organization in which you are an employee, officer, director, trustee
> or general partner own any patents that are related to the research
> project proposal?
>
> \[ \] Yes \[ \] No

\(i\) If Yes, describe the patent(s) and the relationship, if any, to
the objectives and projected outcomes of this research project:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> B. Do you or your spouse, parent, child, general partner, or an
> organization in which you are an employee, officer, director, trustee
> or general partner own or have any financial interest by way of stock
> ownership in a company that owns a patent that is related to the
> research project proposal?
>
> \[ \] Yes \[ \] No

\(i\) If Yes, describe the patent, the financial interest, and the
relationship, if any, to the objectives and projected outcomes of this
research project: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C. To the best of your knowledge does any member of your household,
spouse, parent, child, or any of your relatives with whom you have a
close personal relationship, have any financial interest by way of
investment, employment, or contracts, in a company that owns a patent
that is related to the research project proposal?

> \[ \] Yes \[ \] No

\(i\) If Yes, describe the patent, the financial interest, and the
relationship, if any, to the objectives and projected outcomes of this
research project: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**III. Financial Arrangements**

> A. Do you or your spouse, parent, child, general partner, or an
> organization in which you are an employee, officer, director, trustee
> or general partner have a licensing agreement or other financial
> arrangement that is related to the research project proposal?
>
> \[ \] Yes \[ \] No

\(i\) If Yes, please
describe:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> B. To the best of your knowledge, does any member of your household,
> spouse, parent, child, or any of your relatives with whom you have a
> close personal relationship, have any financial interest by way of
> investment, employment, or contracts, in a company that has a
> licensing agreement or other financial arrangement that is related to
> the research project proposal?
>
> \[ \] Yes \[ \] No

\(i\) If Yes, please describe, and define the relationship, if any, to
the objectives and projected outcomes of this research
project:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**IV. Past and Prospective Employment/Organizational Activities**

A.  Have you, within the last year, served as an officer, director,
    trustee, or general partner, agent, attorney, consultant, contractor
    or employee with any non-Federal entity which may have an interest
    in this research proposal?

> \[ \] Yes \[ \] No
>
> \(i\) If yes, please identify the non-Federal entity and describe your
> employment with the non-Federal entity, and define the relationship,
> if any, to the objectives and projected outcomes of this research
> project: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

B.  Are you negotiating for employment or do you have an arrangement for
    prospective employment with any non-Federal entity?

> \[ \] Yes \[ \] No
>
> \(i\) If yes, please identify the non-Federal entity and describe your
> employment with the non-Federal entity, and define the relationship,
> if any, to the objectives and projected outcomes of this research
> project : \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

C.  Do you serve as an officer, director, committee/subcommittee
    chairperson, advisory member, or perform any promotional/fundraising
    activities for a non-profit or for profit organization which may
    have an interest in this research proposal?

> \[ \] Yes \[ \] No
>
> \(i\) If yes, please identify the organization and the position(s) you
> hold, and define the relationship, if any, to the objectives and
> projected outcomes of this research project:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**V. VA DUTIES**

> Do you have any VA administrative duties that involve research project
> or contract management responsibilities, including oversight,
> approval, advising, recommending, or initiating actions on research
> related projects? (This includes ACOS Research, Dept. Heads, Section
> Chiefs, Membership on R&D Committee or subcommittee (IRB, IACUC,
> Safety/Biosafety) and similar positions. This does not include
> Principal Investigator, Research Project Administrator or Coordinator,
> or similar positions.)
>
> \[ \] Yes \[ \] No

\(i\) If Yes, please
describe:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### VII. Certification {#vii.-certification .unnumbered}

I certify that, to the best of my knowledge and belief, all of the
information on and attached to this disclosure is true, correct,
complete and made in good faith. I understand that false or fraudulent
information on or attached to this disclosure may be grounds for not
accepting the research proposal and may be punishable by fine or
imprisonment (U.S. Code, title 18, section 1001).

Research Team Member's Signature:

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

########  {#section-4 .unnumbered}