Emory University
Conflict of Interest Disclosure Form
For Faculty Participating in Sponsored Research

This form must be completed and filed with your Dean no later than August 31st annually. Any potential or serious conflict which arises during the interim, must be disclosed to your Dean within ten (10) days of your learning of it. Approval of research and training proposals and protocols and acceptance of such awards may be withheld pending receipt of a current disclosure form.

Name: __________________________________________________________

Social Security Number: ________________________________________

Title: _________________________________________________________

Campus Address: ________________________________________________

Department/Division: ___________________________________________

Telephone Number: ______________________________________________

You should refer to Emory's Policies and Procedures for Faculty Members involved in Sponsored Research and Technology Transfer when completing this form. Copies of these Policies and Procedures may be obtained from the Office of Vice President and General Counsel. Telephone: 727-6011.

Questions concerning these Policies or this form should be directed to your Dean, the Office of Vice President and General Counsel or the Office of Sponsored Programs.

1. Please list any business concern, such as a corporation or partnership which anticipates offering or offers, advice, services, or products in the same field as your area of Emory research and : (i) from which you receive, or anticipate receiving, compensation in excess of $10,000.00 during a calendar year in exchange for consulting services or for any other reason; or (ii) is a non-publicly traded company in which you and members of your immediate family, collectively own equity interests greater than 1% or worth more than $10,000.00; or (iii) is a publicly traded company in which you and members of your immediate family collectively own equity interests greater than 1% or worth more than $10,000.00.

2. Please list any business concern, such as a corporation or partnership, which is developing or currently offers a service or product, the commercial success of which will result in your receiving royalties or other remuneration.

3. Please indicate any other relationship, activity or situation of which you wish to apprise your Dean in accordance with the disclosure procedures set forth in Emory's Policies and Procedures for Faculty Members involved in Sponsored Research and Technology Transfer.

I hereby acknowledge that I have received a copy of Emory's Policy and Procedures for Faculty Members involving Sponsored Research and that I have read and do understand the Policies and Procedures.

Signed this _____ day of ______________, 200__.

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