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Study:____________________________________________________________________________________________________

Study Sponsor(s): _________________________________________________________________________________________

Investigator’s Name: _____________________________________________________Telephone: ________________________

This form is to be completed in compliance with Investigator Disclosure of Potential Financial Conflicts of Interest, BH Policy No. 4.2, and must be submitted to the Baptist Health IRB Office at the time of protocol submission. Please refer to BH Policy No. 4.2 for definition of the terms used herein. Answering “YES” to any of the following questions does not necessarily mean that the financial interest is inappropriate or improper, it means only that disclosure and evaluation, and in some cases, approval and oversight, are required. For purposes of this form, “you” refers to you, your spouse (or domestic partner) and your children (or stepchildren).

|1. Compensation |

|a. |Are you currently receiving (or have you received in the past six months) compensation from an individual or business in any way related|YES |NO |

| |to or that might be affected by your proposed research activities? Examples include, but are not limited to, medical director or | | |

| |consulting fees, speaker’s fees, honoraria, gifts or gift funds, salaries, allowances, stipends, dividends, rent, capital gains, real or| | |

| |personal property, etc. | | |

|b. |Are you currently entitled to receive compensation from an individual or business due to intellectual property (e.g., patents, |YES |NO |

| |copyrights, or royalty agreements, etc.) that is in any way related to or that might be affected by your proposed research activities? | | |

|c. |Are you receiving (or do you expect to receive) any type of compensation that could be affected by the outcome of your research |YES |NO |

| |activities? | | |

|2. Ownership or Equity Interests and Leadership Roles |

|a. |Are you currently holding (or have you held in the past six months) any ownership or equity interest in a business enterprise related to|YES |NO |

| |your proposed research activities? Examples include, but are not limited to, stock, stock options, bonds, membership or partnership | | |

| |interests, etc. Note you may exclude ownership or equity interests if (i) such ownership or equity interest arises solely via your | | |

| |investment in mutual funds, pension funds or other institutional investment funds, and (ii) such ownership or equity interest does not | | |

| |exceed in the aggregate $5,000 or 5% ownership in such business enterprise. | | |

|b. |Are you currently holding equity interest in any business enterprise, regardless of value, that could be affected by the outcome of your|YES |NO |

| |research activities? Examples include, but are not limited to, stock, stock options, bonds, membership or partnership interests, etc. | | |

| |Note you may exclude ownership or equity interests if (i) such ownership or equity interest arises solely via your investment in mutual | | |

| |funds, pension funds or other institutional investment funds, and (ii) such ownership or equity interest does not exceed in the | | |

| |aggregate $5,000 or 5% ownership in such business enterprise. | | |

|c. |Are you currently holding (or do you expect to hold) a board, executive or medical director (or CMO) position with the sponsor of the |YES |NO |

| |research or a business with financial interest in the results of the research, regardless of whether you are or are not receiving (or | | |

| |expect or not expect to receive) compensation for the position? | | |

|3. Other |

|a. |Do you have any other financial interests (not covered by Questions 1-2 above) in or with an individual or business that might possibly |YES |NO |

| |be affected by your proposed research activities? | | |

|b. |Is the compensation, remuneration or benefit (of any kind) you receive in any of the above situations, dependent (whether increased or |YES |NO |

| |decreased) on the outcome of your research activities? | | |

If you answered “YES” to any of the above questions, attach a detailed description of the financial interest at issue and the safeguards you will put in place to protect the welfare of research subjects and to ensure that the financial interest does not impact research participants. (Please note that you may be asked for more specific information.)

You hereby certify that you (i) have read and understood Investigator Disclosure of Potential Financial Conflicts of Interest, BH Policy No. 4.2; (ii) have made all required financial interest disclosures; (iii) will comply with any conditions or restrictions imposed by the IRC to manage, reduce, or eliminate conflicts of interest regarding your research activities; and (iv) will promptly update the IRC of any changes to the foregoing that are contemplated or develop during the course of your research activities.

Investigator’s Signature: __________________________________________________ Date: ___________________________

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INVESTIGATOR FINANCIAL RELATIONSHIP DISCLOSURE FORM

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