Xavier University of Louisiana
CONFLICT OF INTEREST DISCLOSURE FORM
I am disclosing the following significant financial interests (see list below and check all that apply) attaching supporting documentation (in an envelope marked Confidential) that identifies the business enterprise or entity involved and the nature and amount of interest.
Significant financial interests are defined as interests valued at greater than $10,000 or an equity ownership of more than 5% held by an Investigator and the Investigatorıs spouse or dependent children. See Conflict of Interest policy for exempt interests.
_____ Salary or other payment for services (e.g., consulting fees or honoraria)
_____ Equity interests (e.g., stocks, stock options, or ownership interests)
_____ Intellectual property rights (e.g., patents, copyrights, and royalties from
such rights
_____ Other significant financial interests of the Investigator that possibly could
affect or be perceived to affect the results of the research or educational
activities funded or proposed for funding.
____ At this time, I have no known conflicts of interest with this proposal.
I agree to: 1) Update this disclosure during the performance period of this award, either on an annual basis, or as new reportable, significant financial interests are obtained; and 2) Comply with any conditions or restrictions imposed by the University to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award.
I have read and understand the universityıs conflict of interest policy and have made all financial disclosures required by it and will comply with any conditions or restrictions imposed by the institution to manage, reduce or eliminate actual or potential conflicts of interest.
______________________________________________ ____________________________
Signature of Investigator Date