WRIGHT STATE UNIVERSITY

CONFLICT OF INTEREST STATEMENT

Proposal No. XX-XXX-XX

(See Reverse Side for Definitions and Instructions

This section is to be completed by Research and Sponsored Programs:

___ This project involves federal funds OR human subjects

___ This project involves neither federal funds nor human subjects

 

This section is to be completed by the Principal/Co-Principal Investigator names on the grant/contract application:*

*Completion is mandatory if project involves either federal funds or human subjects.

___ I do not have a significant personal financial interest, or business relationship with an entity, that may be affected by the outcome of the proposed project.

___ I do have a significant personal financial interest, or business relationship with an entity, that may be affected by the outcome of the proposed project. I will file a "Financial Interest Disclosure" with the Assistant Vice President for Research, RSP [AVP-Research].

 

___________________________________

 

__________

Signature of the Investigator

 

Date

DEFINITIONS & INSTRUCTIONS: The following definitions and instructions are intended to provide guidance to investigators who are completing the Conflict of Interest Statement and Financial Interest Disclosure.

Conflicts of Interest arise when an investigator has significant personal financial interests, or business relationships with an entity, that may be affected by the outcome of the proposed sponsored project. Conflicts of Interest may lead to an action, omission, or situation which compromises the objectivity of the design, conduct, or reporting of the project. Both actual and perceived Conflicts of Interest must be disclosed.

Significant Financial Interests (SFI) are anything of monetary value from a business entity including salary, payments for service, consulting fees, honoraria, equity ownership (stocks, options, notes, etc.) and royalty-bearing intellectual property rights (patents, copyrights, trademarks). Income from an entity or equity in an entity must be aggregated for the investigator, investigator's spouse, and dependent children. However, the term SFI does not include:

  • Salary, royalties, or other payments from Wright State University.
  • Income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities.
  • Income from service on advisory committees or review panels for public or nonprofit entities.
  • Income (e.g., salary, royalties, or other payments) from an entity that is not reasonably expected to exceed $10,000 for the next twelve months.
  • An equity interest in an entity that meets both of the following criteria: (a) Does not exceed $10,000 in value as determined through reference to public prices or other reasonable measures of fair market value, and (b) does not represent more than a five percent ownership interest.

Notes and Comments

  • The above definitions, including the $10,000 and five (5) percent ownership levels, are taken directly from federal regulations.
  • An equity interest in an entity that exceeds $10,000 or 5% does constitute an SFI.
  • If a financial interest arises solely from an investment in a business through a mutual, pension, or other investment fund over which the individual has no control, it will not be considered an SFI.

INSTRUCTIONS

  • The Conflict of Interest Statement must be completed for all WSU proposals. For projects which seek federal funds, Significant Financial Interests which may reasonably appear to affect or be affected by the project must be disclosed.
  • If an SFI is acknowledged on the Conflict of Interest Statement, a Financial Interest Disclosure form must be completed for each business entity in which an SFI exists.
  • The AVP-Research, will determine whether a disclosed financial interest is an SFI and appears to lead to a Conflict of Interest. If not, the decision will be noted and the Financial Interest Disclosure form will be retained with the proposal file. If so, a further review will be initiated according to the WSU policy. (A plan to manage, reduce, or eliminate the Conflict of Interest must be agreed upon before project funds may be expended). In any event, if the project involves human subjects the Financial Interest Disclosure will be submitted to the IRB(s) involved in reviewing the related protocol(s).
  • If an investigator acquires a new SFI, the investigator is obligated to submit a Financial Interest Disclosure within five (5) working days of acquiring the interest.

Reference: Wright State University Conflict of Interest Policy (June 8, 1995)