ࡱ> _ bjbj cici@:$PLG8hK#####$,$V7X7X7X7X7X7X7$:=4|7$##$$|7##Q8&&&$F##V7&$V7&&2b4#v^ %~3B7g8083>%R>0b4b4>v4$$&$$$$$|7|74&R$$$8$$$$>$$$$$$$$$Y M:  CALIFORNIA STATE UNIVERSITY BAKERSFIELD ֱ AUXILIARY FOR SPONSORED PROGRAMS ADMINISTRATION Disclosure of Financial Interests Related to Projects Sponsored by PHS, NIH, NSF, or other Agency Adopting the Federal Requirements In accordance with CALIFORNIA STATE UNIVERSITY BAKERSFIELD or ֱ AUXILIARY FOR SPONSORED PROGRAMS ADMINISTRATION policy on Disclosure of Financial Interests Related to Projects Sponsored by PHS, NSF, or other Agency Adopting the Federal Requirements, the Principal Investigator and all other investigators must disclose their personal significant financial interests (and those of their spouse/registered domestic partner and/or dependent children) related to their institutional responsibilities. This includes the Principal Investigator, Co-Investigators, Senior and Key Personnel, and any other individual who is responsible for the design, conduct, or reporting of research funded by the Public Health Service (PHS), National Science Foundation (NSF), or other sponsors that have adopted the federal requirements for financial disclosure. The information contained in this form may be released or transmitted to the sponsor, including federal agency representatives, and in accordance with the California Public Records Act, it may also be released to the public upon request. Principal Investigator: Name, Last  FORMTEXT      First FORMTEXT      MI FORMTEXT      Proposal/Award Title: FORMTEXT      Project Begin Date FORMTEXT      Project End Date FORMTEXT      Department/Office:  FORMTEXT      Internal Award # (For Existing Award):  FORMTEXT       This FCOI form submission is for either Proposal Submission OR Existing Award (Select One):Sponsor/ Funding Source (Select One): Is CSUB a subcontract?(Select One):Proposal SubmissionExisting Award  FORMCHECKBOX  New Proposal FORMCHECKBOX  New Investigator Added to Project FORMCHECKBOX  Public Health Service or National Institutes of Health FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  New Investigator Added to Project FORMCHECKBOX  Change in Financial Interest  FORMCHECKBOX  National Science FoundationIf subcontract, Prime/ Lead Applicant entity name: FORMCHECKBOX  Change in Financial Interest  FORMCHECKBOX  Annual Financial Interest Disclosure FORMCHECKBOX  Other: _ FORMTEXT      _ FORMTEXT       FORMCHECKBOX  Annual / Non-competing Continuation (Renewal) If Annual Financial Interest Disclosure, Year_ FORMTEXT      __ FORMCHECKBOX  Competing Continuation (Renewal)Disclosures and Certification Each Investigators signature acknowledges responsibility to provide a complete disclosure of all reportable financial interests prior to award receipt, as those interests change, or on an annual basis during the project award period, as required by the funding agency. The Investigator agrees to cooperate in the development of a Resolution Plan to address any actual or potential conflicts of interest identified via this disclosure. The Investigator agrees to comply with any conditions or restrictions imposed by CALIFORNIA STATE UNIVERSITY BAKERSFIELD OR ֱ AUXILIARY FOR SPONSORED PROGRAMS ADMINISTRATION to manage, reduce, or eliminate actual or potential conflicts of interest or forfeit the award. Do you, your spouse or registered domestic partner, or dependent children have any significant financial interests related to your Institutional Responsibilities? (Definitions are specified on page 3 of this form.)  FORMCHECKBOX  No  FORMCHECKBOX  Yes, Investigators Disclosure of Financial Interests Addendum is attached in a separate document. Do you (or will you) benefit from any reimbursed or sponsored travel related to your Institutional Responsibilities? See attached Addendum for more details on what is reportable.  FORMCHECKBOX  No  FORMCHECKBOX  Yes, Investigators Disclosure of Financial Interests Addendum is attached in a separate document. Will Non-ֱ Investigators such as subcontractors or consultants be involved with the PI or campus co-investigators, in the design, conduct, or reporting of the activities associated with the project?  FORMCHECKBOX  No  FORMCHECKBOX  Yes, ֱ must be assured that the affiliated institution/investigator has policies that comply with the funding agencys regulations. Such assurance will be provided with the subrecipient form or in a participant commitment letter to the project. For PHS funded projects, the subrecipient/consultant must indicate their compliance with PHS regulations, or that they will follow the ֱ FCOI policy. (Attach additional disclosures, as required, to identify and include financial disclosure information for all Investigators.) Acknowledgement and Certification I certify under penalty of perjury that this is a complete disclosure of all my significant financial interests related to my institutional responsibilities and that I have used all reasonable diligence in preparing this Financial Interest Disclosure and that, to the best of my knowledge and belief it is true and complete. I also acknowledge by signing my name below that it is my responsibility to disclose, within 30 days, any new significant financial interests obtained during the term of the project period.  FORMTEXT      Investigator s Printed NameSignature of InvestigatorDate Designated Institutional Official Endorsement: I have reviewed this financial interest disclosure and believe that no significant financial interest exists, or if one does exist that a Resolution Plan to manage, reduce, or eliminate any actual or potential conflict of financial interest has been implemented. ________________________________________________________________________________________________  FORMTEXT Signature of Authorized Organizational Representative Date CALIFORNIA STATE UNIVERSITY BAKERSFIELD ֱ AUXILIARY FOR SPONSORED PROGRAMS ADMINISTRATION Investigators Disclosure of Financial Interests Addendum I have reportable financial interests declared on the attached  FORMCHECKBOX  Financial Interest Addendum forms (one for each interest). Name of Interest/Entity:  FORMTEXT       Address of Interest:  FORMTEXT       Owner(s) of Interest:  FORMTEXT       Principal Type of Business:  FORMTEXT       Do you have an investment of $10,000 ($5,000 for PHS) or more in the entity? FORMCHECKBOX  No  FORMCHECKBOX  YesDo you hold an equity position of 5% or more in the entity? FORMCHECKBOX  No  FORMCHECKBOX  YesAre you a director, officer, partner, trustee or employee of the entity? If  yes, please specify below  FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  YesDo you have intellectual property rights (patents, copyrights) being used by the entity or  interest ? If  yes, please specify below  FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  YesIs there an agreement between you and the entity or  interest for deferred remuneration, compensation, or financial gain of any kind? If  yes, please specify below  FORMTEXT       FORMCHECKBOX  No  FORMCHECKBOX  YesFor PHS-funded Investigators, do you (or will you) receive reimbursed or sponsored travel related to your Institutional responsibilities? This does not include travel that is reimbursed or sponsored by a federal, state, or local government agency, an institution of higher education, academic teaching hospital, medical center, or research institute affiliated with an Institution of higher education. If yes, please indicate purpose of trip, sponsor/organizer, destination, and duration below FORMCHECKBOX  No  FORMCHECKBOX  YesPurpose of tripSponsor/organizerDestinationDuration FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Acknowledgement and Certification I certify under penalty of perjury that this is a complete disclosure of all my significant financial interests related to my institutional responsibilities and that I have used all reasonable diligence in preparing this Financial Interest Disclosure and that, to the best of my knowledge and belief it is true and complete. I also acknowledge by signing my name below that it is my responsibility to disclose, within 30 days, any new significant financial interests obtained during the term of the project period. Investigators Printed NameSignature of InvestigatorDate Instructions For PHS/NIH and NSF: The Principal Investigator (PI) and each Investigator must sign the Disclosure and forward it to ֱ GRASP Office with the complete proposal package. Investigators having a significant related financial interest must also complete the Investigators Disclosure of Financial Interests Addendum. Allow sufficient time for the Authorized Institutional Official and the AVP GRASP to complete a review, if necessary, and make a recommendation on award acceptance. Submission of this form is also required on an annual basis for non-competing continuation awards, when a new Investigator is added to the project, or when an Investigators financial interests increase, whichever comes first. For PHS/NIH The de minimis disclosure threshold for a Significant Financial Interest on PHS funded projects is $5,000, which generally applies to payments for services and equity interests. This includes any equity interest in non-publicly traded entities. PIs are required to disclose the occurrence of any reimbursed travel or sponsored travel related to Institutional responsibilities (including purpose of trip, sponsor/organizer, destination, and duration). Disclosure of travel reimbursements and Sponsored Travel does not include 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 (including CSU auxiliary organizations). For other Sponsors who have adopted the Federal disclosure requirements: The Principal Investigator (PI) and each Investigator must sign the Disclosure and forward it to ֱ GRASP Office with the complete proposal package. Investigators having a significant related financial interest must also complete the Investigators Disclosure of Financial Interests Addendum. Definitions Who Must Disclose? Any individual meeting the definition of Investigator, which means the project director or principal investigator and any other person, regardless of title or position, who is responsible for the design, conduct, or reporting of funded research (or proposed for research funding), which may include, for example, collaborators or consultants, and any other individuals (including personnel from other institutions) who are involved in accomplishing project objectives. Investigator may also include students, graduate and undergraduate, and other personnel who may be listed as authors on project results, even if they are not paid from the project. What is a Significant Financial Interest? Anything of monetary value, including, but not limited to: Income exceeding $10,000 (or $5,000 for PHS projects), when aggregated, for an Investigator and the Investigators spouse and dependent children from a single Entity (Business, Public or Nonprofit) including salary, consultant payments, honoraria, royalty payments, dividend, loan, or any other payments or consideration with value. Income from a Public or Nonprofit Entity for seminars, lectures, teaching engagements, or service on advisory committees or review panels is exempt; Equity in the form of stock, stock options, real estate, loan to, or any other investment or ownership interest exceeding $10,000 and does not represent more than a 5% ownership interest in any single entity (or $5,000 for PHS projects for any ownership interest), for any one enterprise when aggregated for an Investigator and the Investigators spouse and dependent children; A management position such as board member, director, officer, partner or trustee held by the Investigator, the Investigators spouse and/or dependent children; or Intellectual property interest held by the Investigator, or Investigators spouse or dependent children on a patent, patent application, or a copyright of software assigned or to be assigned to a party other than the CSU. Financial Interest does not include (1) payments made by CSU Bakersfield or ֱ Auxiliary for Sponsored Programs Administration (salary, royalties, honoraria, expense reimbursement or any other remuneration) or (2) an investment by a mutual fund, pension fund or other investment fund over which the investigator or his/her immediate family member does not exercise management of fund investment. What is a Related Financial Interest? The work to be performed under the sponsored project and results therefrom would reasonably appear to affect the financial interest of the Investigator or the financial interest of the Entity in which the Investigator has an interest. 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The AVP GRASP will provide an assessment as to whether any of that entitys financial interests, or the Investigators financial interests related to consulting for that entity, would reasonably appear to be affected by the federally-sponsored research; The Investigator has a financial interest in an entity and the sponsored project proposes to subcontract a portion of the work, or lease property, or make referral of participants to, or make purchases from the entity; or The Investigator has a financial interest in an entity that is part of a consortium or that will otherwise participate in the sponsored project.  FORMTEXT Review Process The Office of Grants, Research and Sponsored Programs will review the disclosure information to ensure completeness and consistency with prior disclosures. Information provided in the Disclosures of those Investigators having a Related, Significant Financial Interest and additional appropriate documentation shall be forwarded to the Associate Vice President for Grants, Research and Sponsored Programs. The AVP GRASP will consider whether the financial interests of the Investigator or the Entity could be directly and significantly affected by the proposed sponsored project and whether the financial interest could affect the design, conduct, or reporting of the project. A direct impact occurs when the project results would be directly relevant to the development, manufacturing, or improvement of the products or services of the entity in which the employee has a financial interest, or when the entity is a proposed subcontractor or participant in the project. A significant impact on the financial interest is one that will materially affect the value of the organization, its earnings, or the sale of its products. The AVP GRASP will review the information and make a recommendation as to how a management plan should be developed. Records: The information provided herein may be released or transmitted to the sponsor, including federal agency representatives, and according to the California Public Records Act, may also be released to the public, upon request. These records will be retained for 3 years after termination of the sponsored project or until resolution of any action by the sponsor, whichever is greater.     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