Federal American Funding Agencies: Disclosure of Significant Financial Interests

formID_#098

Disclosure of Significant Financial Interests

In line with Uppsala University’s guidelines (Dnr UFV 2021/1302), the Principal Investigator (PI) and other investigators that share responsibility for the design, conduct or reporting of projects sponsored by federal American agencies, must declare their Significant Financial Interests.

This digital form must be submitted before application submission to any federal American agency, as well as annually thereafter (if the application is granted). If a significant financial interest is obtained during the term of the award, the form must be submitted without delay.

If you are involved in a granted project sponsored by the National Institutes of Health (NIH), you are also required to complete this tutorial prior to engaging in the NIH-funded research, and every four years thereafter, as long as you are involved in NIH-funded research: http://grants.nih.gov/grants/policy/coi/tutorial2011/fcoi.htm.

Please note: the questions in the form below will unfold depending on your previous answers.

• Funding agency:
• Project title:
• Name of investigator:
• Department:
• Reason for disclosure: - - - Submission of a new grant application This is an annual update The project has a new investigator I have obtained a new interest
• Funding Opportunity Title:
• Funding Opportunity Number:
• Federal award identification number (FAIN):
• Project year: - - - 1 2 3 4 5 6 7 8 9
• Federal award identification number (FAIN):
• Federal award identification number (FAIN):

• Disclosure Statement of Significant Financial Interests

• 1. Compensation from commercial entities

• Within the last 12 months have you, your spouse and/or dependent children received compensation of any kind from any commercial entity that reasonably appears to be related to your institutional responsibilities? - - - Yes No
  (i.e., teaching, research, clinical or administrative duties). Compensation includes, but is not limited to, compensation from 1) consulting fees, 2) honoraria for lectures, papers or teaching, 3) salaries or officer/director's fees, 4) gifts or gratuities, or 5) royalty payments
• The compensation was for (check all that apply):
  You

  Your spouse

  Your dependent child
• According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question? - - - Yes No

• Please download this compensation form:

   Compensation form 
  

  Fill out the compensation form and upload it to the "Upload an account of the compensation from commercial entities" below.

• Upload an account of the compensation from commercial entities
  Bläddra...

  
  In this account, for each and every entity, describe the form of compensation, the name of the entity, and the amount/value of compensation per year. Also, justify your answer to the question “According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question?"
  
  • ()

• 2. Ownership in stocks, stock options and other form of ownership in publicly and non-publicly traded companies

• Do you, your spouse and/or dependent children own stocks, stock options or other forms of ownership in any commercial entity that reasonably appears to be related to your institutional responsibilities? - - - Yes No
  (i.e. teaching, research, clinical or administrative duties)
• Is this an ownership in publicly traded companies? - - - Yes No
• The ownership in publicly traded companies is held by (check all that apply):
  You

  Your spouse

  Your dependent child
• According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question? - - - Yes No
• Is this an ownership in non-publicly traded companies? - - - Yes No
• The ownership in non-publicly traded companies is held by (check all that apply):
  You

  Your spouse

  Your dependent child
• According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question? - - - Yes No

• Please download this Ownership in companies form:

   Ownership in Companies 
  

  Fill out the form and upload it to the "Upload an account of the ownership in publicly traded and/or non-publicly traded companies" below.

• Upload an account of the ownership in publicly traded and/or non-publicly traded companies.
  Bläddra...

  
  In this account, for each and every entity, describe the form of ownership, the name of the entity, whether it is a publicly traded company or non-publicly traded company, value of ownership, and whether you are in direct control of the investment decisions made in this ownership. Also, justify your answer to the question “According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question?
  
  • ()

• 3. Ownership in intellectual properties

• Are you, your spouse and/or dependent children named in any income generating intellectual property rights and interests (e.g. patent, copyrights), the value of which would reasonably appear to be related to your institutional responsibilities? - - - Yes No
  (i.e. teaching, research, clinical or administrative duties)
• If yes, who has the ownership of the patent? Please check below all that apply:
  You

  Your spouse

  Your dependent child
• According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question? - - - Yes No

• Please download this ownership in intellectual properties form:

   Ownership in Intellectual Properties 
  

  Fill out the form and upload it to the "Upload an account of the ownership in intellectual properties" below.

• Upload an account of the ownership in intellectual properties
  Bläddra...

  
  In this account, describe the form of ownership in intellectual properties, the name of the entities involved (and values for each and every entity). Justify your answer to the question “According to you, does this financial interest appear to be affected by the conduct or outcome of the proposed research?"
  
  • ()

• 4. Travel and/or accomodation sponsored by commercial entities

• In the last 12 months, did any commercial entity that reasonably appears to be related to your institutional responsibilities (i.e. teaching, research, clinical or administrative duties) pay for or reimburse you (and/or your spouse/dependent children) for any travel (e.g. hotel, transportation)? - - - Yes No
• According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question? - - - Yes No

• Please download this travel form:

   Travel form 
  

  Fill out the travel form and upload it to the "Upload an account of travels" below.

• Upload an account of travels:
  Bläddra...

  
  In this account, for each and every travel that has been sponsored or paid for by a commercial entity, state the name of the entity, the purpose of the travel, the destination, the duration, whether the entity paid for your spouse/dependent child to travel with you, and the actual or estimated monetary value of the travel. Also, justify your answer to the question “According to you, does this financial interest appear to be affected by the conduct or outcome of the research project in question?
  
  • ()

• Certification of disclosure

• Please download this certification of disclosure document:

   Certification of disclosure 
  

  Fill out the certification of disclosure document and upload it to the "Attach a document with your digital signature" below.

• Attach a document with your digital signature
  Bläddra...

  
  
  • ()

• Please note: When you submit your application, please do not close your browser until you have been redirected to another page with a confirmation of a successfully received application.

• Significant financial interest means:

  (1) A financial interest consisting of one or more of the following interests of the Investigator (and those of the Investigator's spouse and dependent children) that reasonably appears to be related to the Investigator's institutional responsibilities:

  (i) With regard to any publicly traded entity, a significant financial interest exists if the value of any remuneration received from the entity in the twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of disclosure, when aggregated, exceeds $5,000. For purposes of this definition, remuneration includes salary and any payment for services not otherwise identified as salary (e.g., consulting fees, honoraria, paid authorship); equity interest includes any stock, stock option, or other ownership interest, as determined through reference to public prices or other reasonable measures of fair market value;

  (ii) With regard to any non-publicly traded entity, a significant financial interest exists if the value of any remuneration received from the entity in the twelve months preceding the disclosure, when aggregated, exceeds $5,000, or when the Investigator (or the Investigator's spouse or dependent children) holds any equity interest (e.g., stock, stock option, or other ownership interest); or

  (iii) Intellectual property rights and interests (e.g., patents, copyrights), upon receipt of income related to such rights and interests.

  (2) Investigators also must disclose the occurrence of any reimbursed or sponsored travel (i.e., that which is paid on behalf of the Investigator and not reimbursed to the Investigator so that the exact monetary value may not be readily available), related to their institutional responsibilities; provided, however, that this disclosure requirement does not apply to travel that is reimbursed or sponsored by a Federal, state, or local government agency, an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education. The Institution's FCOI policy will specify the details of this disclosure, which will include, at a minimum, the purpose of the trip, the identity of the sponsor/organizer, the destination, and the duration. In accordance with the Institution's FCOI policy, the institutional official(s) will determine if further information is needed, including a determination or disclosure of monetary value, in order to determine whether the travel constitutes an FCOI with the PHS-funded research.

  (3) The term significant financial interest does not include the following types of financial interests: salary, royalties, or other remuneration paid by the Institution to the Investigator if the Investigator is currently employed or otherwise appointed by the Institution, including intellectual property rights assigned to the Institution and agreements to share in royalties related to such rights; any ownership interest in the Institution held by the Investigator, if the Institution is a commercial or for-profit organization; income from investment vehicles, such as mutual funds and retirement accounts, as long as the Investigator does not directly control the investment decisions made in these vehicles; income from seminars, lectures, or teaching engagements sponsored by a Federal, state, or local government agency, an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education; or income from service on advisory committees or review panels for a Federal, state, or local government agency, an Institution of higher education as defined at 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an Institution of higher education.