PHS & Non-PHS Financial Conflict of Interest Disclosure Statement

Before completing this Financial Conflict of Interest Disclosure Statement, please review the Rady Children's Hospital - San Diego Financial Conflict of Interest Related to Public Health Service or Non- Public Health Service Sponsored Research Policy (CPM-11-96 or CPM 11-109).

To access the FCOI related to Public Health Services Research policy, please 'click' here: Financial Conflict of Interest Related to Public Health Service Sponsored Research Policy (CPM 11-96).

To access the FCOI related to Non-Public Health Services Research policy, please 'click' here: Financial Conflict of Interest Related to Non-Public Health Service Sponsored Research Policy (CPM 11-109).

All Principal Investigators and Key Personnel listed on any PHS or Non-PHS study must complete this disclosure statement annually. Detailed information on who is considered "key personnel" is mentioned in the above policy.

All RCHSD staff must first complete the "Promoting Objectivity and Transparency in Research" module within Rady Children's Learning Center (RCLC) before completing the FCOI form. You do not need to complete this training in RCLC if you have done so within the last 3 years. If you have not, Logon at:
"Promoting Objectivity and Transparency in Research"and search for "promoting objectivity” to find the training module. Please forward your training certificate to research@rchsd.org so that we may track your FCOI training certification.

Please contact Rady Children's Hospital Office of Research Administration at (858)966-5934 or at research@rchsd.org if you have any questions.

Please Note: Failure to submit this information could result in non-acceptance of your award from the proposed sponsor or delay in the Ready to Accrue letter supplied by Research Administration.

*This question is required.

New Disclosure Statement
Annual Disclosure Statement
Revised/Updated Disclosure Statement

Principal Investigator / Co-Principal Investigator / Key Personnel / Project Information: *This question is required.

First Name *This question is required.

Last Name *This question is required.

Title *This question is required.

Department *This question is required.

Phone Number *This question is required.

Email Address *This question is required. This question requires a valid email address.

Project Title *This question is required.

RCHSD Project Number (4 digit RAMP #) *This question is required.

Comments

Is there an entity/sponsor related to this project in which you have a financial interest? *This question is required.

Related entity/sponsor information. *This question is required.

	Entity/Sponsor Name:
	Entity/Sponsor Business Type:
	Street Address
	City, State, Zip

Comments

I. Description of Financial Interest:

A. Management *This question is required.1. Do you, your spouse, registered domestic partner, or dependent child(ren) hold a position of management or employment with this entity?

If Yes, please indicate the position(s). *This question is required.

2. Describe the responsibilities of your position(s) with the entity and how they relate to the project funded by the entity. *This question is required.

B. Income *This question is required.

1. Excluding gifts, contracts or grants administered by Rady Children's Hospital San Diego, have you, your spouse, registered domestic partner, or dependent child(ren) received income from the entity/sponsor named above in the past 12 months?

Income Range and Nature of Income:

*This question is required.

$0 - $4,999
$5,000 - $9,999
$10,000 - $19,000
$20,000 - $29,0000
$30,000 and above (write in amount) Please enter an 'other' value for this selection.

Nature of Income: *This question is required.

2. Do you have a loan arrangement with the entity/sponsor? *This question is required.

Provide the loan Amount: $ *This question is required.

Explain the arrangements: *This question is required.

C. Equity *This question is required.

1. Do you, your spouse, registered domestic partner, or dependent child(ren) hold an equity interest in this entity/sponsor?

2. What is the percentage of equity *This question is required. This question requires a valid percent format.

3. What is the nature of this equity interest? *This question is required.

Bonds
Stocks/Stock Options
Convertible Security
Other Please enter an 'other' value for this selection.

4. What is the value of this equity interest? *This question is required.

Note: If stock is not publicly traded, provide an internal estimate of value: $

D. Consulting *This question is required.

1. Are you a consultant with this entity/sponsor?

2. Do you have a written consulting agreement (non-Hospital agreement)? *This question is required.

If yes, provide a copy which will be returned to you.

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3. Describe in detail the frequency and nature of your consulting activities and how the consulting is separate from your research.

*This question is required.

4. Will the terms of your consulting in any way restrict the release of information or other dissemination of research results by faculty/researchers involved in the project?

*This question is required.

Please enter an 'other' value for this selection.