MICHIGAN STATE UNIVERSITY
Significant Financial Interest Disclosure And Proposal Certification Form Pertaining to Applications for NSF and PHS Research Support
The NSF and PHS financial
disclosure regulations are designed to ensure that the design, conduct, and
reporting of research funded under PHS or NSF grants, cooperative agreements or
contracts will not be biased by any conflicting financial interest of those
investigators responsible for the research. Under these regulations, faculty
applicants to NSF or PHS must disclose to the University potential conflict of
interests, and the University must manage, reduce, or eliminate disclosed
financial conflicts of interest. Disclosure forms with "yes" answers
to either or both of the following questions are to be forwarded to the
Conflict Review Committee, a three-member faculty panel chaired by an assistant
vice president for research as a non-voting member.
I. Do you, your spouse, and your dependents, in the aggregate, have, in any outside entity* related to the proposed sponsored project, any ownership interests (stock, stock options, and/or any dept, security or capital holding) that have a current market value of $10,000 or more or that represents 5% or more of the total equity? (Do not report holdings in mutual funds or TIAA/CREF.)
II. Do you, your spouse, and your dependents, in the aggregate, receive salary or other remuneration or financial considerations equal to or more than $10,000 per year from any entity* related to the proposed project?
*Any entity related to the proposed sponsored project would include any non-MSU: supplier of equipment, materials or services related to the research; business commercializing a product that the research is intended to evaluate or further develop; party whose financial interests would seem to be directly and significantly affected by the research.
I have read and understood the University’s Guidelines
for Potential Conflicts of Interest Pertaining to Applications for NSF and PHS
Research Support and, to the best of my knowledge, I have made all required
financial disclosures.
I will comply with any conditions or restrictions imposed by the University to manage conflicts of interest. Should my outside financial or managerial interests, or those of my spouse or dependents, change during the next calendar year so as to change my answer on any of the above questions, I agree to submit a revised Disclosure Form.
I certify that the statements made in the
referenced proposal application are true, complete and accurate to the best of
my knowledge. I am aware that any false, fictitious, or fraudulent statements
or claims may subject me to criminal, civil, or administrative penalties. I
agree to accept responsibility for the scientific conduct of the project and to
provide the required progress reports if a grant is awarded as a result of this
application.
Investigator’s Name (please print) _______________________________________________________________
Title of Project _____________________________________________________________________________
Funding Agency and Program (provide APP or account number if know) _____________________________
Other MSU Co-Investigators ______________________________________________________________________
Investigator’s Signature__________________________________________________Date______________________
Primary Review:
Chair or Director’s review: Does a potential conflict of interest exist? NO Yes (Please Describe)
· Chair or Director’s Signature ____________________________________________Date______________________
Dean’s review: Does a potential conflict of interest exist? NO Yes (Please Describe)
· Dean’s Signature ______________________________________________________Date______________________
(When the Investigator is an administrator, the Primary Review will be completed by the Provost and the Vice President for Research and Graduate Studies.) Jan. 96