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Annual Outside Interest Disclosure for Affiliates of WFBMC  

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 Affiliate Clinic:  
                              Job Title:
  Tax Year (previous calendar year, January - December):  

I have read and understand the WFBMC Conflict of Commitment and Conflict of Interest Policy




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 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, limited to those entities in your field of practice and/or those entities that do business with WFBMC.

  • 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, name the entity and 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, name the entity and describe activity:  
  Provide the income received:
  Question 3: Did you or a member of your immediate family have a paid or unpaid managerial role, director, board member, or company officer with an external business entity?
  If Yes, name the entity and describe the 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 an invention or technology?
  If Yes, describe the invention or technology:  
  If royalties were received, provide the name of the distributing entity:  
  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 research I may conduct or assist with.  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

Ways to Give
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