Financial Interest Disclosure Form - Harvard University



Financial Interest Disclosure Form

Instructions: Principal Investigators are responsible for ensuring that this form is completed for each member of the research staff reporting a financial interest related to the research. For more information about Harvard conflict of interest policy, visit:

| A. PROTOCOL INFORMATION |

|Protocol Number: |       |

|Protocol Title: |       |

|Principal Investigator or Faculty Advisor / Degree(s): |     /      |

|B. RESEARCH STAFF WITH FINANCIAL INTEREST. |

|Name (first, last degree): |     ,       |

|“Immediate Family” means spouse, domestic partner, and dependent children. |

|“Related to the Research” means any interest in the sponsor, product or service being tested, or competitor of the sponsor held by the individual or the |

|individual’s Immediate Family: |

|Do you or your Immediate Family have any ownership interest Related to the Research of any value including, but not limited to | Yes No |

|stocks and options, exclusive of interests in publicly-traded, diversified mutual funds. | |

|Do you or your Immediate Family have any compensation Related to the Research of any amount including, but not limited to | Yes No |

|honoraria, consultant fees, royalties, or other income. | |

|Do you or your Immediate Family have any proprietary interest Related to the Research of any value including, but not limited to| Yes No |

|patents, trademarks, copyrights, and licensing agreements. | |

|Do you or your Immediate Family have any board or executive relationship, Related to the Research regardless of compensation. | Yes No |

|For more information, contact the office of technology department at . | |

|Do you or your Immediate Family have any reimbursed or sponsored travel Related to the Research of any amount by an entity other| Yes No |

|than a federal, state, or local government agency, higher education institution or affiliated research institute, academic | |

|teaching hospital, or medical center. | |

|C. DESCRIPTION AND MANAGEMENT OF FINANCIAL INTERESTS |

|Describe the financial interest(s) (include the dollar value/amount if applicable; indicate whether any arrangements have been entered into whereby the |

|value of the interest would be affected by the outcome of the research):       |

|If you have a proposed or established plan to manage the financial interest, describe it here:       |

|D. IRB USE ONLY |

| Conflict of Interest not directly related to protocol; no further action required |

|Conflict of Interest appropriately managed, reduced, or eliminated; no further action required |

|Conflict of Interest deferred to full Board |

|Other:       |

|____________________________________________________ ____________________ |

|Reviewer Name/Signature Date |

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