Disclosure of Investigator Financial Interests

If you have a question pertaining to a Financial Conflict of Interest, as defined by the National Institutes of Health, of an Investigator at Wake Forest Baptist Medical Center you may request it using the form below.

Your request must meet the criteria established by the National Institutes of Health (NIH) related to public accessibility.

The Institution will respond in writing within five business days of any request for information concerning Significant Financial Interests disclosed to the Institution if they meet the following three criteria:

1. The Significant Financial Interest was disclosed and is still held by the Investigator for the NIH-funded research project identified by the Institution in the grant application, progress report, or any other required report submitted to the NIH;

2. The Institution determines that the Significant Financial Interest is related to the NIH-funded research; and

3. The Institution determines that the Significant Financial Interest is a Financial Conflict of Interest.

The information that the Institution makes available via written response shall include, at a minimum, the information required by the regulation 42 CFR Part 50 Subpart F.

Please note: If you submit a request which does not meet the above criteria, you will receive a written response within five business days indicating your request did not meet the NIH reporting requirements. 


 

Instructions: A response is required in each of the fields below.  Once you have entered the information, click on the Submit Form button below.

 

Last Name of Requester

   

First Name of Requester

 
   

Email Address

 
   

Name of Investigator

 
   

Study Title or
Nature of Research

   
   

 

Quick Reference

Contact Information
Conflict of Interest Office

Main 336-716-9300

Departmental email
coioffice
@wakehealth.edu

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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.