Skip to Content

Significant Financial Interest Disclosure

In order to submit the form successfully, you must supply an answer to each question. You will receive a copy of the completed form in a confirmation email after submission.

Disclosure Type *

Definition of Significant Financial Interest

A Significant Financial Interest is a financial interest consisting of one or more of the following interests of the Investigator (and those of the Investigator’s spouse and dependent children) that reasonably appears to be related to the Investigator’s research and other institutional responsibilities. For purposes of this definition, remuneration includes salary and any payment for services not otherwise identified as salary (e.g., consulting fees, honoraria, paid authorship); equity interest includes any stock, stock option, or other ownership interest, as determined through reference to public prices or other reasonable measures of fair market value.

  • Income from investment vehicles such as mutual funds and retirement accounts is NOT a Significant Financial Interest UNLESS the Investigator directly controls the investment decisions made in these vehicles. 
  • With regard to any publicly traded entity, a significant financial interest exists if the value of any remuneration received from the entity in the twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of disclosure, when aggregated, exceeds $5,000.
  • With regard to any non-publicly traded entity, a significant financial interest exists if the value of any remuneration received from the entity in the twelve months preceding the disclosure, when aggregated, exceeds $5,000, or when the Investigator (or the Investigator’s spouse or dependent children) holds any equity interest (e.g., stock, stock option, or other ownership interest);
  • Intellectual property rights and interests (e.g., patents, copyrights), upon receipt of income related to such rights and interests.
  • Travel related to institutional responsibilities that is reimbursed or sponsored by an entity other than a federal, state, or local government agency, institution of higher education as defined at 20 U.S.C. 1001(a), academic teaching hospital, medical center, research institute that is affiliated with an Institution of higher education
A. Have you, your spouse or your dependent children received anything of monetary value including, but not limited to, any salary, consulting fees, honoraria, or paid authorship from one or more publicly-traded entities in the 12-month period preceding the date of this disclosure which reasonably appears to be related to your research and other institutional responsibilities? *
B. Do you, your spouse or your dependent children own stock, stock options, or other ownership interests in one or more publicly-traded entities which reasonably appear to be related to your research and other institutional responsibilities? *
If you answered YES to Question A or B: does the value of the remuneration in the combined with the value of the stocks, stock options, or other ownership interests in Question B, valued as of the date of this disclosure, exceed $5,000? (If you answered No, select N/A) *
Have you, your spouse or your dependent children received anything of monetary value including, but not limited to, any salary, consulting fees, honoraria or paid authorship, that when aggregated exceeds $5,000, from a private, non-publicly-traded entity (e.g., start-up, limited liability company, sole proprietorship) in the 12-month period preceding the date of this disclosure which reasonably appears to be related to your research and other institutional responsibilities? *
Do you, your spouse or your dependent children own or hold ANY ownership interest in a private company or organization which reasonably appears to be related to your research and other institutional responsibilities? *
Have you, your spouse or your dependent children received ANY income from intellectual property rights (e.g. patents, licenses, and copyrights) or interests not held by Texas State University in the 12-month period preceding this disclosure which reasonably appears to be related to your research and other institutional responsibilities? *
Have you, your spouse or your dependent children engaged in any travel related to your research or institutional responsibilities, in the 12-month period preceding the date of this disclosure, that is sponsored or reimbursed by any entity OTHER THAN a federal, state, or local government agency, institution of higher education, academic teaching hospital, medical center, or research institute that is affiliated with an institution of higher education? *

Certification

University Logo
  • I certify that the above information is complete and true to the best of my knowledge and that I have been informed of Texas State University's policy and procedures related to conflict of interest, the Federal Regulation Promoting Objectivity in Research (42 CFR Part 50, Subpart F), and my responsibility for disclosing Significant Financial Interests (SFI) and Financial Conflicts of Interest (FCOI).  
  • By submitting this form, I acknowledge that the information may be disclosed to persons and entities including, but not limited to, the ORSP, Texas State University personnel, research sponsors, state and federal oversight agencies, as necessary to comply with terms of grants, contracts or other agreements and to determine and ensure compliance with applicable laws, regulations, policies, and procedures.
  • I acknowledge my responsibility to submit an updated form when there is a change in my financial interests related to my institutional responsibilities.
  • I acknowledge that if I am a Principal Investigator, it is my responsibility to ensure that other members of the research team submit their disclosures and update those disclosures on an ongoing basis as their circumstances change.
  • I acknowledge that if I have disclosed the existence of SFI, I will be asked to provide additional information as required to determine whether or not an FCOI exists.
  • I acknowledge that if an FCOI exists, I may be required to participate in the implementation of a plan to manage, reduce, or eliminate the conflict.