Tulane University Conflict of Interest Form

Tulane University

Conflict of Interest Disclosure Form

In order to comply with recently revised rules and regulations of the Department of Health and Human Services and the National Science Foundation, Tulane has adopted a revised Conflict of Interest Policy, a copy of which is attached. Please answer the following questions, using additional sheets if necessary. Terms in bold type are defined in the Policy.

YES

_____		NO

_____
  • Have you performed consulting or engaged in outside employment during the past academic year? If yes, list the name(s) of the organization(s), the duties performed, and the time devoted to the activity.




YES

_____		NO

_____
  • Do you have outside professional or income producing activities involving University students? If yes, please describe.




YES




_____


_____


_____

_____		NO




_____


_____


_____

_____
  • Do you or any member of your immediate family (spouse and dependent children, including step children) have a consulting relationship or a significant financial interest (a financial interest which exceeds $10,000 or 5% ownership when aggregated for your immediate family) in:

    a business which tests, markets or produces a product which would be evaluated or further developed through your research activities?

    a business that does business with Tulane, which business you are in a position to influence?

    a sponsor of your research?

    any other business in which there could be an appearance of a conflict of interest or which could reasonably appear to be affected by your research interests or educational activities?

    If yes, please describe.




YES

_____		NO

_____
  • Do you hold any position or appointment as an officer, director, or provide service in a management capacity in an commercial, industrial, business or financial organization which does business with or has a relationship with the University? If yes, please describe.




YES

_____		NO

_____
  • Is there any other relationship or activity of which you wish to apprise your Dean in accordance with the disclosure procedures set forth in the COI Policy? If yes, please describe.




I hereby acknowledge that I have read and understood the Conflict of Interest Policy.


Signed this ______ day of ___________________, l99_.


_______________________________________________
Signature


_______________________________________________
Printed name


_______________________________________________
Department/School

Return this form to the Dean of your school or college. For questions or additional information, please call your Dean or the Office of the Vice President for Research, 865-5272 or 584-1625.





Office of Research

Conflict of Interest Policy

This page updated October18, 1996