ࡱ> Z]Y i1bjbjߍ 0TY)8DVLKf,c"vvvvFvvvV@*IVN 0KZx-#v-#vvK-# :   FACULTY CONFLICT OF INTEREST QUESTIONNAIRE and REPORT FORM In responding to the following questions, please review the attached explanations pertinent to the scope of each question. Name: __________________________________________ Telephone Number: _______________________ Address: _________________________________________________________________________________ Relationship To : _______________________________________________________________ [e.g., Professor of Physics] 1. Stock Ownership or Outside work a. Do you or any member of your immediate family own stock or act as an officer, director, agent, consultant, or employee of any company that does business with , where you presently represent or assist in doing business with that firm? b. If you have answered 1a in the affirmative, please list the name of the firm, your business title and role, and the percentage of interest you or your immediate family own in the outside business. Please attach your business card, if you have one, as well. What are the areas of potential conflict between your outside firm and 's position? 2. College Facilities, Equipment or Personnel a. Do you propose to use facilities, equipment or personnel to conduct commercial or industrial research or development for any outside firm? b. If you have answered 2a in the affirmative, please supply relevant details about the transaction, including the proposed compensation arrangements, and please explain why the proposed use of facilities or personnel is in the best interests of . 3. NSF Activities a. Do you conduct or propose to conduct research or educational activities funded by the National Science Foundation (NSF) in which you act as principal, co-principal or other investigator? b. If you answered 3a in the affirmative, please explain the nature of your duties, and the amount of consideration that you have received, or expect to receive, for these services. c. If you answered 3a in the affirmative, do you or any member of your immediate family have any significant financial interest that would or might be directly and significantly affected by the research or educational activities funded or proposed to be funded by NSF? d. If you answered 3c in the affirmative, please describe the nature of the financial interest which might be affected by your research or educational activities funded by NSF. If the financial interest of an entity in which you and/or members of your immediate family own stock or hold positions might be directly and significantly affected by such activities, please list the name of the entity, your business title and role, and the percentage of interest you or your immediate family own in the entity, and describe how the activities for NSF might affect the financial interests of such entity. 4. Research Supervision Do you now supervise any students, residents, or fellows in any research which is either (a) supported by an outside firm in which you have an interest identified in response to question 1 of this form or which, while not supported by such firm, relates to work that you are doing for the firm, or (b) supported by NSF funding for a project that you are performing or propose to perform. If so, please provide details of the arrangements. SCOPE OF THE PARTICULAR QUESTIONS: For Question 1, Stock Ownership and Outside Work a. When to File. The reporting requirements under this question are not triggered simply because you have a personal business connection or financial investment with a firm that does business with . You must also be in a position where you represent in transactions with that firm. The purpose of the question is to alert a responsible administrative official to a possible conflict of interest. Thereafter, an independent inquiry will be conducted to determine whether it is appropriate for you to represent or assist in its dealing with an outside firm. Where you wish to keep your outside activities confidential, you may choose not to represent or assist in the transaction in question. b. Other Business Ventures. Where you seek to market or test an invention or process developed in the service of , using facilities or personnel, or requiring the study or treatment of human subjects in a project, then the approval of the Dean of the Faculty is necessary. c. Represent or Assist. The scope of these two terms is as follows. Represent covers those cases where you, alone or with others, negotiate directly with an outside firm. Assist covers those cases where you participate in the internal deliberations within on whether, and if so how, to deal with the outside firm. Assistance will normally occur when you are asked to participate on a committee that reviews purchasing and other business options for , e.g., the buying or leasing of a major computer system. d. Substantial Investment or Business Connection. The question of what counts as a substantial financial connection may vary over time. As of this writing, any business transactions done within a given year with a firm that total less than $10,000 are not to be regarded as substantial. Similarly, any holding in a public corporation that represents less than five percent of the value of such corporation's outstanding publicly held securities is not regarded as substantial. In making your calculations about corporate ownership, disregard any shares that you own indirectly through a publicly controlled mutual or pension fund or similar investment vehicle. e. Immediate Family. The definition of an immediate family includes your spouse, children, siblings, and parents, as well as all blood relations and in-laws living in your residence. f. Extent and Nature of Disclosures. There is no need to disclose the financial value of your interest within the business, or any other confidential information about it. Nor need you make disclosures about the form of your financial interest, e.g., whether you own stock, warrants, or options. However, if there is some annual statement or report about your outside business that you think will help resolve any conflict of interest questions, please feel free to attach a copy to this form. While the initial statement may be quite brief, further information may be required in order to resolve the conflict question adequately. All information will be held confidential to the extent that is allowable by law. You may withdraw from your involvement in a particular transaction at any time in order to eliminate a conflict of interest. For Question 2, Use of College Facilities, Equipment or Personnel a. Covered Activities. It is expected that you will reimburse for all expenses incurred in servicing your outside activities, including phone, supplies, mailing expenses, and computer times. (Lump sum approximations are acceptable to avoid the burdens of detailed accounting for small sums.) Where possible you might wish to have these services billed directly to the outside organizations. b. Review of Proposal. It is expected that all proposals for use of facilities, equipment or personnel shall be reviewed by the Dean of the Faculty. Your response should indicate how the overall transaction benefits , and how will be compensated for use of its resources in the proposed transaction. For Question 3, NSF Activities a. Meaning of significant financial interest. In responding to question 3c, the term significant financial interest to be disclosed means anything of monetary value, including, but not limited to, salary or other payments for services (e.g., consulting fees or honoraria); equity interest (e.g., stocks, stock options or other ownership interest); and intellectual property rights (e.g., patents, copyrights and royalties from such rights). However, the term significant financial interest does not include: salary, royalties or other remuneration from ; or any ownership interests in , if is an applicant under the Small Business Innovation Research Program or Small Business Technology Transfer Program; income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities; income from service on advisory committees or review panels for public or nonprofit entities; or financial interests in business enterprises or entities if the value of such interests does not exceed $5,000 or represent more than a five percent ownership interest for any one enterprise or entity when aggregated for the investigator and the investigator's spouse and dependent children. b. Meaning of directly and significantly affected. In responding to question 3c, the terms directly and significantly affected are not defined in the NSF disclosure policy. If a significant financial interest (defined above) exists, then an actual or potential conflict of interest may exist if that financial interest could affect the design, conduct or reporting of the research or educational activities funded or proposed for funding by NSF. Accordingly, if you have any significant financial interest (as defined above) in the subject matter of the NSF project, you should respond to 3c in the affirmative; then disclose in your response to 3d the details of your financial interest and your explanation of how that financial interest may or may not be affected by your participation in the NSF project to provide some basis for the reviewer to reach a judgment on whether your financial interests are directly and significantly affected. c. Report Updates. NSF policies require updates of disclosures during the pendency of the NSF award, either on an annual basis, or as new reportable significant financial interests are obtained. You may therefore be requested to update your responses to meet these requirements. In addition, should your financial interest in the subject matter of the NSF project change at any time, you should take the initiative to file an updated disclosure form. For Question 4, Research Supervision Your response should give assurances that the research connection is consistent with the educational mission of and the normal progress of the student toward the desired degree. 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