Introduction

Federal regulations and institutional policy require that all persons responsible for the design, conduct or reporting of a proposed research project, contract, sub-contract, agreement or protocol must disclose Significant Financial Interests (SFIs) that reasonably appear to be related to their institutional responsibilities. This requirement extends to collaborators, postdocs, students, residents, and consultants.  

When are disclosures required?

  • At the time a project is proposed (new grant submission, new contract executions, new protocol submissions)
  • Annually
  • Within 30 days of acquiring any new Significant Financial Interest.

Determining what you must report

If ANY of the following apply to you, answer “YES” to the statement at the bottom of this page.

In the 12 months preceding this disclosure, have you or your family members had a Significant Financial Interest (SFI) in ANY:

Publicly-Traded Entity 
in which your combined equity value (ownership of stock, options, etc.) AND income exceeded $5,000 and that entity appears to be related to your institutional responsibilities;

Non-Publicly-Traded Entity   

in which you had an ownership interest of ANY value OR income exceeding $5,000 (from any one entity), and that entity appears to be related to your institutional responsibilities;

Intellectual Property   
from which you received ANY income, and the intellectual property appears to be related to your institutional responsibilities;

Sponsored Travel

paid for, or reimbursed directly to you, by any organization OTHER THAN an accredited, U.S. institution of higher education (including LLUH) or any U.S. government agency (federal, state, or local); and the purpose of the travel or the sponsoring organization appears to be related to your institutional responsibilities; and the dollar value of the travel in the aggregate from this sponsor exceeds $5,000 in the last 12 months;

A Paid Position of Influence 

in which you had any authoritative or direction-shaping role in any entity NOT affiliated with LLUH (including non-profit organizations) and the interests of the entity appear to be related to your institutional responsibilities.

For Procurement Conflict of Interest

Introduction

The Procurement Standards in the Uniform Guidance of the Federal Code of Regulations (2 CFR 200.318(c)(1)) requires that no employee, officer, or agent must participate in the selection, award, or administration of a contract supported by a Federal award if he or she has a real or apparent conflict of interest. The officers, employees, and agents of the non-Federal entity must neither solicit nor accept gratuities, favors, or anything of monetary value from contractors or parties to subcontracts.

When are disclosures required?

You are obligated to provide a new or updated disclosure

  • Annually
  • Promptly upon acquiring any actual or potential conflict of interest

Determining what you must report

If ANY of the following apply to you, answer “YES” to the statement at the bottom of this page.

  • You or any member of your immediate family, your partner, or an organization which employs or is about to employ any of the parties indicated herein, have a financial or other interest in or a tangible personal benefit from a firm that could be considered for a procurement contract.

In your role at LLUH, you make purchasing decisions or otherwise influence the organization’s decision to do business with a supplier/contractor affiliated with you or your immediate family members or any other individual who would be perceived as a potential conflict.

SECTION I. Researcher Information

Name

SECTION II. Significant Financial Interests disclosure

In the 12 months preceding this disclosure, have you or your family members had a Significant Financial Interest (SFI) in ANY (choose 'yes' or 'no' for each question):

Publicly-Traded Entity in which your combined equity value (ownership of stock, options, etc.) AND income (in any one entity) exceeded $5,000 and that entity appears to be related to your institutional responsibilities;
Non-Publicly-Traded Entity in which you had ANY ownership interest OR income exceeding $5,000 (from any one entity), and that entity appears to be related to your institutional responsibilities;
Intellectual Property from which you received ANY income and the intellectual property appear to be related to your institutional responsibilities;

Or received:

ponsored Travel $5,000 or more that is paid for, or reimbursed directly to you, by any organization OTHER THAN an accredited, U.S. institution of higher education (including LLUH) or by any U.S. government agency (federal, state, or local) and the sponsoring organization appears to be related to your institutional responsibilities;

Or held:

A Position of Influence in which you had any authoritative or direction-shaping role in any entity NOT affiliated with LLUH (including non-profit organizations) and the interests of the entity appear to be related to your institutional responsibilities.

If you have checked 'Yes' to any of the above, complete Sections IV and V on pages 3-5.

If you have checked 'No' to all of the above, complete Section III below.

Note: If "No," this declaration satisfies disclosure requirements for all research projects in which you participate for a period of one year. However, if you acquire new financial interests, this provision will end and you must disclosure any new financial interest within 30 days.

Section III. I certify that:

  • I have reviewed Research Conflict of Interest Policy, and understand my obligations.
  • The information submitted within this form is true, complete and accurate to the best of my knowledge.
  • Any false, fictitious, or fraudulent statements may subject me to criminal, civil, or administrative penalties.

Section IV. Project-specific Significant Financial Interest disclosure for investigators with known significant financial interests. Complete a separate form for each outside company/entity.

Company or Entity Type
Please select one
1. Have you or your family held any position or served on an advisory board or board of directors for this entity?
Position Title:
Position Held By:
2. Have you or your family owned assets in this entity?
Asset Type:
Assets Owned By:
3. Have you or your family received income from this entity?
Income Type:
Income Received By:
4. Have you or your family received any reimbursed/sponsored travel related to your institutional responsibilities?
Travel Provided For:
Intellectual Property Type:
Intellectual Property Owned By:
Annual Amount:
6. Have these intellectual property rights been assigned to Loma Linda University Health or its affiliated corporations?
7. Do you have an agreement with Loma Linda University Health or its affiliated corporations to share in royalties related to these intellectual property rights?

Section V. I certify that:

  • I have reviewed Research Conflict of Interest Policy, and understand my obligations.
  • The information submitted within this form is true, complete and accurate to the best of my knowledge
  • Any false, fictitious, or fraudulent statements may subject me to criminal, civil, or administrative penalties.