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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