FORM OSP -
DIVISION OF RESEARCH
State University of New York at Binghamton
OFFICE OF SPONSORED
PROGRAMS
Conflict of Interest Form Annual Disclosure of Financial Interests and
Obligations
As part of its commitment to promoting objectivity in research and in compliance with federal regulations on
conflict of interest, Binghamton University has adopted an Annual Disclosure Policy. This policy requires that
the investigators submit an annual disclosure form to ensure that the design, conduct and reporting of sponsored
program activity will not be biased by the significant financial interests or obligations of any investigator. To
comply with this policy, each investigator must submit an annual disclosure form on or before October 1, but no
later than:
·
submission of an application to an external sponsor, or
·
acceptance of an award where there was no prior disclosure submitted for that work
The submission of this annual disclosure satisfies the requirements of the Department of Health and Human
Services (PHS) and the National Science Foundation (NSF). These agencies require that, by the time an
application is submitted, each investigator planning to participate in PHS or NSF-funded research has disclosed
his/her known significant financial interests (and those of his/her spouse and dependent children) ( 42 CFR Part
50 Subpart F and 45CFR Part 94 and Section 510 of the NSF Grant Policy Manual).
Questions concerning this policy or the annual disclosure should be addressed to Stephen A. Gilje, Associate
Vice President for Research (
sgilje@binghamton.edu
).
PO Box 6000, Binghamton, NY, 13902-6000. Ph: (607) 777-6
136. FORM OSP Revised 09/08
FORM OSP
-
DIVISION OF RESEARCH
OFFICE OF SPONSORED
State University of New York at Binghamton
PROGRAMS
Conflict of Interest Form Annual Disclosure of Financial Interests and
Obligations
All Binghamton University investigators seeking external sponsored funding to conduct scholarly activities are
required to complete and file a signed disclosure form each year. Each investigator must complete this form
before a proposal can be endorsed for submission.
Specific Instructions: Place a check in the appropriate column for each question. Once every question is
answered, the investigator must certify the information by signing the bottom of the form. The completed
annual disclosure should be placed in a sealed envelope, marked confidential, and forwarded to the Stephen A.
Gilje, Associate Vice President for Research, Division of Research. Sponsored Programs will not endorse
submission of your sponsored programs application until your annual disclosure form has been submitted.
Sponsored Funds Administration will not release your award until it has been determined that an up-to-date
disclosure is on file.
Investigator Name:
Department/School:
Questions
Yes* No
Do you, your spouse or dependent child(ren) hold a position of management, such as
board member, director, officer, partner, trustee, employee or consultant with a sponsor, a
vendor or (sub) contractor related to the sponsored program activity?
Do you, your spouse or dependent child(ren) have significant financial interest in a
Sponsor, a vendor or (sub) contractor related to your sponsored program activity?
Significantly financial interest includes stock, stock options, and/or any other ownership
interest valued at more than $10,000 or 5% ownership.
Is it reasonable to anticipate that your financial interest could be directly and significantly
affected by the design, conduct, or reporting of your sponsored program activity?
Investigator Certification:
·
I have read and understood the Conflict of Interest Policy
·
I agree to file a new or updated Investigator Disclosure Form if the answer to any of the above questions
changes.
·
I certify that the answers to the declaration are accurate and truthful to the best of my knowledge.
Signature:
Date:
*
If the answer to any question is Yes, please contact the Associate Vice President for Research prior to
submission of this form.
PO Box 6000, Binghamton, NY, 13902-6000. Ph: (607) 777-6
136. FORM OSP Revised 09/08