Significant Financial Interest Disclosure : AVP-Research and Federal Relations : Texas State University

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.

Texas State email address *

Last Name *

First Name *

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.

Disclosure Type *

Annual Disclosure

PHS-Funded Investigator new to Texas State

Update to Previous Disclosure

Have you received a Notice of Award for PHS funding (including non-competing continuations) since August 24, 2012? *

Yes

Are you planning to apply, or is there a possibility that you may apply, for PHS funding (including noncompeting continuations) in the 12-month period following this disclosure? *

Yes

Not Sure

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

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? *

Yes

B. Do you, your spouse or your dependent children own stock, stock options, or other ownership interests in one or more publicly-traded entities? *

Yes

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) *

Yes

Not certain

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? *

Yes

Do you, your spouse or your dependent children own or hold ANY ownership interest in a private company or organization? *

Yes

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? *

Yes

Have you, your spouse or your dependent children engaged in any travel related to your 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

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.

Office of the Provost

AVP-Research and Federal Relations

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.

Public Health Service (PHS) funding status

Definition of Significant Financial Interest

Certification

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.