Conflict of Interest Disclosure for Subrecipients of WFBMC 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 of immediate family members) that are related to their research on this project.

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 the requested information for the previous tax year (January-December). If you have questions, please contact our office.

Confirm Understanding of the Policy

I have read and understand the research-related provisions of the WFBMC Policy on Conflict of Interest (Section III).
What to Disclose

The following questions pertain to any outside entities with which you (or an immediate family member - related by blood, marriage or adoption) had a relationship during the previous calendar year (January - December) that could be perceived as a conflict of interest on this project. Outside entities include companies, service providers, non-government organizations (NGOs), foundations, and any other for-profit or not-for-profit entities (includes entities outside of the U.S.).

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.

Assurance and Certification

I hereby acknowledge that I have read and understand the research-related provisions of the WFBMC Policy on Conflict of Interest.

I affirm that the information I provided is to the best of my knowledge true and complete and does not misstate any facts.

I will provide any additional information as requested by the WFBMC 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 real or perceived conflicts of interest related to this research project.  I agree to comply with the terms and conditions contained in any Management Plan developed for this research project.