Spreadsheet: 05134e9a-a7d2-4568-bc6e-d21d405fde48
Sheet: CoI & Cert

Bellarmine University
Conflict of Interest Disclosure & Certification Form
Related to Sponsored Projects
**All BU faculty/staff intending to participate in an externally-funded (sponsored) project must complete this form prior to submitting the proposal.**
Faculty / Staff name:
Proposal title:
Proposal / Application forwarded to: |  |  |  |  |  | (sponsor / funding agency)
Provide the names of all the members of the Board of Directors and the Board of Trustees of the funding agency: (enter below, or attach list)
MY ROLE ON THIS SPONSORED PROJECT:      (select only ONE)
 |  | PI or Co-PI
 |  | Participating faculty/staff member
 |  | Undergraduate student………………… |  | Full-time or Part-time undergrad?
 |  | Graduate student
 |  | Other……. | explain……………….
RESEARCH CONFLICT OF INTEREST
To promote objectivity, some federal agencies have issued regulations aimed at ensuring that the design, conduct, and reporting of funded research will not be biased by any conflicting financial interest of the individual(s) responsible for the research.  It is the policy of the University that any faculty or researcher who is an investigator applying for or receiving research funding from any entity outside of the University disclose any financial interests which would reasonably appear to be affected by such research.  To comply with the regulations and policies regarding conflict of interest, please verify that you have thoroughly read and understand the BU Faculty Council policy located at:  http://www.bellarmine.edu/documents/FacultyCouncil/ConflictsofInterest12106.doc.
Indicate which ONE statement below is true:
 |  | I have read and understand the BU Faculty Council policy on Conflict of Interest.
 |  | I have not read and/or do not understand the BU Faculty Council policy on Conflict of Interest.
FINANCIAL CONFLICT OF INTEREST (applies to all externally-funded projects/proposals)
An actual or potential conflict of interest occurs when an employee is in a position to influence a decision or action which may result in a personal gain for that employee or for a relative (person related by blood or marriage).  Policy 9.2.1.8 requires disclosure of any actual or potential conflict of interest so that safeguards can be established to protect all parties.  The purpose of this form is to identify, manage, reduce, or eliminate any actual or potential conflicts of interest, which may be presented by compensated outside activities or other financial interests, of persons who could affect the research, design, conduct, or reporting of externally-funded projects.  To help ensure that Bellarmine employees will not be biased by any conflicting financial interest, please answer the following questions.  For this purpose, "financial interest" is anything of monetary value, other than your BU salary.
1) |  | Do you, or any of your family members, have (or could reasonably be perceived to have) any financial interest related to the work to be conducted under this sponsored project?  ( YES / NO )
2) |  | Do you, or any of your family members, have (or could reasonably be perceived to have) any financial interest in any entity providing funds for your project?  ( YES / NO )
3) |  | Do you, or any of your family members, have (or could reasonably be perceived to have) any financial interest in any entity which owns intellectual property that could reasonably appear to be affected by the work performed under this project?       ( YES / NO )
4) |  | Do you, or any of your family members, have (or could reasonably be perceived to have) any financial interest in any entity that could be affected by this project’s success or failure?  ( YES / NO )
5) |  | Do you serve as a paid consultant, officer, administrator, board member, or speaker for any entity that is providing funds for your project, that could reasonably appear to be affected by your project, or that has an interest in intellectual property that could reasonably appear to be affected by your project?  ( YES / NO )
6) |  | Are you, or any of your family members, currently or formerly related to any member of the sponsor's Board of Directors or Board of Trustees?  ( YES / NO )
7) |  | Is there anything not covered in the above questions that you believe might constitute a conflict of interest or create the appearance of being a conflict of interest related to your project?  ( YES / NO )
If you answered 'yes' to any question, please provide a detailed explanation below (attach additional pages as necessary) including the name of any entity in which you have, or may appear to have, a related financial interest and the associated monetary value, as well as any familial relationship with any member of the sponsor's Board of Directors and/or Board of Trustees.
By initialing below, I further agree:
 | (initial if you agree) |  | a) I agree to update this form during the period of the award, at least annually or more often if new financial interests are obtained.
 | (initial if you agree) |  | b) I agree to cooperate in the development of any plan which would constitute a Conflict of Interest Resolution Plan, if necessitated by a violation of this policy.
I certify that the above is a full and truthful disclosure of all entities in which I or my family members have financial interest related to this sponsored project.  I understand that this disclosure may be shared on a limited need-to-know basis with other institutional officials and/or external sponsors.
 | Signature |  |  |  | Date Signed
*********   Forward this completed document to the Office of Academic Affairs.   *********
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CERTIFICATION by the VP of ACADEMIC AFFAIRS/Conflicts Coordinator (or VPAA designee):
By signing below, I hereby certify that I have reviewed this form and have determined that:    (please check one)
 |  | The information contained here does not indicate a conflict of interest, and I recommend approval.
 |  | A real OR potential conflict of interest exists but can be reduced, eliminated or managed in the following way:
 |  | A conflict of interest exists and I cannot recommend approval.
 | Signature |  |  |  | Date Signed
 | Title
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CERTIFICATION by the VP of ADMINISTRATION AND FINANCE (or VPAF designee):
Certification is required by the VPAF, or VPAF designee, when one or more of the above 7 questions were answered with a "yes" response.
 | I   (agree)    (disagree)   with the determination made by the Office of Academic Affairs.
 | Signature |  |  |  | Date Signed
 | Title