Conflict of Interest Disclosure for Subrecipients of WFUHS Research Funding  

Subrecipients who elect to follow WFBMC financial conflict of interest policy are required to disclose to the Institution any outside interests and financial relationships with Industry or other outside organizations (including outside interests or immediate family members) that are related to their research.

The WFBMC Conflict of Interest Office will advise subrecipients on managing any associated conflicts of interest which might arise in personal outside financial relationships.

Please provide financial information for the previous tax year (January-December).  If you have questions, please contact our office at 336-716-9300.

  Last Name:
  First Name:
  Email Address:
  Name of Your Institution or Entity:  
                             WFUHS PI:
  Grant Number:
  Tax Year (previous calendar year, January - December):  
     
     
 

I have read and understand the research-related provisions of the WFBMC Conflict of Commitment and Conflict of Interest Policy (Section IV). 

 

 

     
 

What to Disclose

The following questions relate to any entities with which you (or an immediate family member - related by blood, marriage or adoption) have income, equity, intellectual property rights or fiduciary relationships related to your research in the previous calendar year (January - December).  Outside entities include companies, service providers, non-government organizations (NGOs), foundations, and any other for-profit or not-for-profit entities.

  • Income - Disclose any income earned from providing labor or services to an outside entity (includes but not limited to consulting, advisory boards, speaking, paid editorial services).
  • Equity holdings or ownership - Disclose any shares of equity owned, including stock options, warrants or promises of such, etc., whether the company is privately or publicly held and even if there is no current value.  Ownership in mutual funds is excluded.
  • Intellectual property rights/License agreements - Disclose intellectual property rights owned, license agreements and/or royalties received, including those paid to you by WFBMC.
  • Fiduciary responsibility - Disclose fiduciary responsibilities with any outside entities (for-profit and not-for-profit), including but not limited to board memberships, company officer role or executive management role, whether paid or unpaid.
 
     
  Question 1: Did you provide speaking, consulting or expert testimony and/or have an income-producing relationship with an external business entity?
     
  If Yes, describe activity:  
  Provide the income received:
     
  Question 2: Did you or a member of your immediate family receive unrestricted support, unrestricted grant, contract and/or gifts (either monetary, products, or equipment) from an external business entity?  
     
  If Yes, describe:  
  Provide the value and/or income received:
     
  Question 3: Did you or a member of your immediate family have a paid or unpaid managerial, director, board member, or company officer role with an external business entity?
     
  If Yes, describe activity:  
     
  Question 4: Did you or a member of your immediate family own intellectual property rights or interests, have pending license agreements, or receive royalty payments related to your research?
     
  If Yes, describe the invention or technology:  
  If royalties were received, provide the income:
     
  Question 5: In the previous 12 months, have you had any travel sponsored or reimbursed to you, regardless of the amount, by a for-profit or nonprofit entity, excluding federal, state or local government, a U.S. institution of higher education, or an affiliated medical center, hospital or research institute?  
     
  If Yes, name the entity/entities who sponsored or reimbursed your travel:    

Assurance and Certification

  • I hereby acknowledge that I have read and understand the WFBMC Conflict of Commitment and Conflict of Interest Policy.
  • I affirm that the information provided is to the best of my knowledge true and complete and does not misstate any facts.
  • I will provide any additonal information as requested by the Conflict of Interest Office.
  • I agree to cooperate in the development of any needed Management Plan as required per the Federal Regulations to manage, reduce or eliminate existing conflicts of interest related to my research.  I agree to comply with the terms and conditions contained in any Management Plan.

 

 

Quick Reference

Contact Information
Conflict of Interest Office

Main 336-716-9300

Departmental email
coioffice
@wakehealth.edu

Ways to Give
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Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.