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.
Public Health Service (PHS) funding status
Please take care regarding your answer to the following questions regarding PHS funding. "PHS funding" refers to federal grant funding from one of the awarding components of the Public Health Service within the Department of Health and Human Services (DHHS).
List of PHS funding agencies.
Before you identify yourself as a PHS-funded Investigator or answer Yes on the next question regarding recent notification of PHS award please make sure you are correct. If your funder is not on the list, then please do not identify yourself as a PHS-funded investigator or answer Yes to the question regarding PHS funding notification.
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 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;
- 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
- 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 AVPR, 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.