Spreadsheet: 2caf18f3-e55a-4702-9f8d-817c042769e2
Sheet: Sheet1

THE UNIVERSITY OF TULSA | Unnamed: 1 | Unnamed: 2 | Unnamed: 3 | Unnamed: 4 | Unnamed: 5 | Unnamed: 6 | Unnamed: 7 | Unnamed: 8 | Unnamed: 9 | Unnamed: 10 | Unnamed: 11
CONFLICT OF INTEREST DISCLOSURE FORM FOR RESEARCH AND SPONSORED PROGRAMS
A conflict of interest may take many various forms but exists when there is a divergence between an individual's private interest and his/her professional obligations to the University such that an independent, reasonable observer might conclude there is a possibility of influence by consideration of gains, financial or otherwise, for the individual, his/her immediate family or domestic partner.  In order to avoid this situation and to comply with Government regulations and University policy, this form must be completed with each request for funding prior to the submission of the proposal.
Information disclosed shall be considered CONFIDENTIAL
Investigator: |  |  |  |  |  | Department/Unit:
Sponsor:
Project Title:
Yes |  |  |  |  |  |  |  |  |  |  | No
 | 1 |  | Do you* have:
 |  | A. | a consulting or other financial relationship with the proposed sponsor?
 |  | B. | a managerial role with the proposed sponsor?
 |  | C. | direct ownership (e.g. stock, stock options, real estate investment, etc.) or other ownership or interests in the proposed sponsor?
 | 2 |  | Does the sponsor hold:
 |  | A. | patent rights or copyrights to an invention(s) created by you*?
 |  | B. | license rights from TU on any invention(s) created by you*?
 | 3 |  | Will the proposed sponsor manufacture and/or commercialize any product involved in or that will predictably result from this research project?
 | 4 |  | Do you* use TU facilities and/or personnel to conduct activities for the proposed sponsor outside the scope of work of a University sponsored agreement?
 | 5 |  | Do you* supervise students or other researchers in activities conducted for the proposed sponsor outside the scope of work of a University sponsored agreement?
 | 6 |  | Will an immediate family member(s) or domestic partner be supported by or participate in this project?
 | 7 |  | To the best of your knowledge, does a potential or perceived conflict of interest exist with any student, post doc, undergraduate or other person to be employed under or involved with this project?
 | 8 |  | Is a third party providing cost sharing or participating in the project that you* have a financial relationship with that includes, but is not limited to, those listed under Questions 1. A,B,C and 2.A,B (above)?
 | 9 |  | Is there any other potential conflict of interest that may exist on this project?
 | 10 |  | Is the potential financial interest related to any of these questions in excess of $10,000?
 | 11 |  | Could an independent, reasonable person envision a potential conflict of interest on this project that might influence your research findings?
If you answered "yes" to any of the above questions, please attach a statement of explanation(s).  Additional information may be required by the Dean of your College and the Vice President for Research prior to the submission of this proposal.
I certify that the above information is true and that I accept responsibility for being familiar with the University of Tulsa Policy on Conflict of Interest for Research and Sponsored Programs (www.utulsa.edu/research/).  I understand that this information must also be disclosed as new reportable significant financial interests are determined and failure to comply with these policies shall constitute grounds for disciplinary action.
Investigator (PI/Co-PI/Other) |  |  |  |  |  |  |  |  | Date:
Upon review of this document and explanations provided, a potential conflict of interest does __/does not __ appear to exist.
Chair/Director/Unit Head |  |  |  |  |  |  |  |  | Date:
If a conflict of interest does appear to exist, a management plan is __/is not __ required.
[NAME] |  |  |  |  |  |  |  |  | Date:
If required, a management plan has been reviewed and has __/has not __ been approved by the Vice Provost for Research.
Vice Provost for Research |  |  |  |  |  |  |  |  | Date:
*"you" is defined as you, your immediate family member(s) or domesic partner