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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 completed form once the office of College Grants & Sponsored Programs reviews your disclosures and signs-off on the form.

Investigator*

Prefix (optional)

First Name

Initial (optional)

Last Name

Organization*

Union College

Other:

Email Address*

How many active and/or pending sponsored projects are you currently PI, co-PI, or senior personnel on? You will be asked to provide information for each sponsored project.*

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?*

Yes - Please describe the nature and extent of the affiliation(s) below No

Please describe the nature and extent of the affiliation(s):*

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?*

Yes - Please describe the nature and extent of the interest(s) below No

Please describe the nature and extent of the interest(s):*

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?*

Yes - Please describe the amount of income and the reason for which it was or will be derived below No

Please describe the amount of the income and the reason for which it was or will be derived:*

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*

I prefer to type out my name and enter the date I prefer to draw my signature and enter the date

Investigator Name*

Prefix (optional)

First Name

Initial (optional)

Last Name

Date of Certification*

Investigator Signature*

[clear]

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:*

No financial conflict of interest appears to exist A financial conflict of interest may exist but has been previously reported, reviewed, and appropriately mitigated A financial conflict of interest may exist and this disclosure will be forwarded to the Dean of the Faculty for review and appropriate mitigation

Notes

Type of Electronic Signature*

I prefer to type out my name and enter the date I prefer to draw my signature and enter the date

Grant Administrator Name*

Prefix (optional)

First Name

Initial (optional)

Last Name

Grant Administrator Title*

Date of Certification*

Grant Administrator Signature*

[clear]

Use your mouse or finger to draw your signature above

Grant Administrator Title*

Date of Certification*

Union College - Disclosure Statement Regarding External Affiliations

Sponsored Project 1

Sponsored Project 2

Sponsored Project 3

Sponsored Project 4

Sponsored Project 5

Sponsored Project 6

Disclosures

Investigator Certification

Certification by the Office of College Grants & Sponsored Programs