Union College - Disclosure Statement Regarding External Affiliations

Form for disclosing external affiliations for compliance with the policy on investigator financial interests and conflicts of interest. Please refer to the Investigator Financial Interests and Conflicts of Interest Policy while completing this form.

This form will be reviewed by the office of College Grants & Sponsored Programs. If it is determined that a financial conflict of interest may exist, the disclosure will be forwarded to the Dean of Faculty.

You will received a copy of your competed form once the office of College Grants & Sponsored Programs reviews your disclosures and signs-off on the form.

Investigator*
Organization*

Sponsored Project 1

Project Role*
Status*
Project Start Date*
Project End Date*

Sponsored Project 2

Project Role*
Status*
Project Start Date*
Project End Date*

Sponsored Project 3

Project Role*
Status*
Project Start Date*
Project End Date*

Sponsored Project 4

Project Role*
Status*
Project Start Date*
Project End Date*

Sponsored Project 5

Project Role*
Status*
Project Start Date*
Project End Date*

Disclosures

Are you or a member of your immediate family (spouse, domestic partner, or dependent children) an officer, director, partner, trustee, employee, advisory board member, or agent of any of the external organizations funding the sponsored project(s) listed above, or of any external organization whose financial interests would reasonably appear to be affected by the sponsored project(s) listed above?*
Are you or any member of your immediate family (together or separately) the actual or beneficial owner of more than five percent (5%) of the voting stock or controlling interest of: a) The external organization funding the sponsored project(s) listed above; b) Any external organization from which goods and services will be obtained under the sponsored project(s) listed above; or c) Any external organization whose financial interests would reasonable appear to be affected by the sponsored project(s) listed above?*
Have you or any member of your immediate family (together or separately) derived income within the past year, or do you or any member of your immediate family (together or separately) anticipate deriving income exceeding $10,000 per year from: a) The external organization(s) funding the sponsored project(s) listed above; b) Any external organization(s) from which goods and services will be obtained under the sponsored project(s) listed above; or c) Any external organization(s) whose financial interests would reasonably appear to be affected by the sponsored project(s) listed above?*

Investigator Certification

By providing an electronic signature below  and submitting this form, I certify that:

A. I have read and understand the Union College Investigator Financial Interests and Conflicts of Interest Policy
B. To the best of my knowledge, I have made all required financial disclosures
C. I agree to comply with any conditions or restrictions imposed by Union College for the purpose of managing or eliminating any actual or potential conflicts of interest related to this grant. If I am unable to comply, I understand the College may decline the grant award.

Type of Electronic Signature*
Investigator Name*
Date of Certification*
Use your mouse or finger to draw your signature above
Date of Certification*

Certification by the Office of College Grants & Sponsored Programs

After reviewing the form provided by the investigator, I certify that:*
Type of Electronic Signature*
Grant Administrator Name*
Date of Certification*
Use your mouse or finger to draw your signature above
Date of Certification*