Investigator Significant Financial Interest Disclosure Form

Investigator Significant Financial Interest Disclosure
(See Wellesley College Investigator Significant Financial Interest Disclosure Policy for Sponsored Projects)

Faculty/Employee Name: ____________________________________________________

Department/Unit: __________________________________________________________

Proposal Title: ____________________________________________________________

Proposal Submitted To: _____________________________________________________

I am disclosing the following significant financial interests (check one or more) that would reasonably appear to be affected by the research or educational activities funded, or proposed for funding, by an external sponsor. I attach supporting documents (in an envelope marked confidential) that identify the business entity or enterprise involved and the nature and amount of the interest.

_____Salary or other payment for services (e.g., consulting fees or honoraria)

_____Equity interests (e.g., stocks, stock options, or other ownership interests)

_____Intellectual property rights (e.g., patents, copyrights, and royalties from them)

_____Other interest that could affect or be perceived to affect the results of the research or educational activities funded or proposed for funding.

Further I agree:

to update this disclosure form during the period of the award or as new significant financial interests are obtained;
to cooperate in the development of a Memorandum of Understanding (MOU) that constitutes a conflict of interest resolution plan;
to comply with any conditions or restrictions imposed by the college to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award; and,
to have a fully executed MOU in place prior to making any expenditures of sponsored project funds.

Signed: _______________________________________________Date: _____________

(original signature only -- a "per" signature is not acceptable)

Endorsement:

I have reviewed the significant financial interest disclosure and believe that it will be possible to develop and execute, prior to expenditure of award funds, an MOU to manage, reduce, or eliminate any actual or potential conflict of interest.

Dean of the College: ______________________________________Date:______________