ࡱ> bda] ~IbjbjZ!Z! d8K4\8K4\ 2228jT2"B*@@@8$V"X"X"X"X"X"X"$'X"9tt"X"@@4"XXXF@@V"XV"XX  @G\5\LR B""0" ,[(H[( [( dXX"X"r"[(> :  In accordance with VCOMs Financial Conflicts of Interest in Research Policy, all Investigators must disclose financial interests in an external entity that provides funding or support for the research project or that has an interest in the results of the research. This form must be submitted, even if the individual has no financial interests to disclose. Please see Instructions on the following page.Full Name: FORMTEXT      Division: FORMTEXT      Title of Research Project: FORMTEXT      Funding/Support Source: FORMTEXT       Research-Specific DisclosuresWithin the past 12 months or for the next 12 months, have or will you, your spouse, your domestic partner or your dependent children or any foundation or entity controlled by you or your spouse: FORMCHECKBOX  YES FORMCHECKBOX  NOReceive consulting fees, royalty, honoraria, gifts or other payments or in kind compensation from an external entity that may appear to affect or be affected by the conduct or outcome of the study, for consulting, lecturing, service on an advisory board or for any other purpose not directly related to the costs of conducting research? FORMCHECKBOX  YES FORMCHECKBOX  NOReceive any reimbursement for travel, or have travel paid for, by an entity that may appear to affect or be affected by the conduct or outcome of the study? (This does not include travel paid by government agencies, teaching hospitals, medical centers or institutions of higher education.) FORMCHECKBOX  YES FORMCHECKBOX  NOHold any outside position (officer, director, trustee, consultant, employee, etc.) with an entity that may appear to affect or be affected by the conduct or outcome of the study? FORMCHECKBOX  YES FORMCHECKBOX  NOHave ownership interests of any nature, including equity, stock options, etc., in an external entity that may appear to affect or be affected by the conduct or outcome of the study? FORMCHECKBOX  YES FORMCHECKBOX  NOHave an intellectual property interest in a patent, patent application or copyright assigned or licensed (including those assigned to VCOM) to an external entity that may appear to affect or be affected by the conduct or outcome of the study? If you answer Yes to any of the above questions, you must provide additional information by completing the Supplemental Research FCOI Disclosure Form. Acknowledgement and Certification I hereby certify that the above information is complete and true to the best of my knowledge, and that I have read and understand the SWAGƵFinancial Conflicts of Interest in Research Policy, and agree to comply with such Policy. I acknowledge that I am responsible for submitting an updated Research Financial Conflict of Interest Disclosure Form, within 30 days, prior to any change in my financial or other interests that may appear to affect or be affected by this study. Signature:Date: All research personnel who have a responsibility for the design, conduct or reporting of research must complete this form. Please see instructions on following page. If you have questions, please contact the Office of Research Administration. Instructions Under this Policy, Investigator is defined as the principal investigator and all others who have responsibility for the design, conduct or reporting of research (including data collection and data analysis). A financially interested company is an entity with financial interests that would reasonably appear to be affected by the outcome or conduct of the research. Please type your answers in the designated fields below, save and print out the disclosure form. Once you have signed, please submit the completed form to the principal investigator. The principal investigator is responsible for submitting all disclosure forms to the Office of Research Administration along with the application. To learn more about disclosure requirements and what constitutes a potential conflict of interest, please see the  HYPERLINK "http://www.vcom.vt.edu/facultystaff/policies/" \l "/50/" SWAGƵFinancial Conflicts of Interest in Research Policy. This form is not required for research that has no external funding or no financially interested company. If you checked Yes to any of the questions, you must provide additional information regarding the entity involved and the nature and amount of the interest for the applicable 12-month period via the Supplemental Research FCOI Disclosure Form found at:  HYPERLINK "http://www.vcom.edu/ora/forms.html" http://www.vcom.edu/ora/forms.html. 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Failure to include the Supplemental form when reporting a financial interest on this form may result in delays in the review and submission process of the grant application.      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