Financial Disclosure Form for Researchers

Financial Conflict of Interest Disclosure Statement

This form is to be completed in connection with the Saint Luke’s Health System Policy on Financial Conflict of Interest in Research, ADM 015 by all key personnel who are involved in the review, design, analysis, conduct and/or reporting of research in which an entity of Saint Luke’s Health System is engaged or is reviewed by the Saint Luke’s Hospital Institutional Review Board. Answers should be completed based on the 12 months prior to form completion.

Should you have questions about the form, you may contact:
IRB@saint-lukes.org

The Saint Luke’s Hospital Institutional Review Board, Central Office of Research Administration and Financial Conflict of Interest Committee will protect the confidentiality of private investments and personal finances and will request information related only to financial relationships that might influence the objectivity of research being conducted.

Your answer(s) to the questions do not imply that any financial interest you disclose is improper or impermissible. However, failure to report a financial interest or furnishing false, misleading or incomplete information may constitute professional misconduct and could be cause for disciplinary action.

You must fill out a separate form for each company in which you have a financial interest and update each form as changes occur.

Prefer the paper version? Download the Financial Disclosure Form (docx).

By checking the above, I am stating that I do not, nor does any member of my immediate family, have any financial interests that include, but are not limited to, compensation for any consulting fees, royalties, fiduciary roles, advisory services, equity interests, travel, or other financial interests as defined.
I participate in research funded by PHS or its subsidiaries
Company
1) Research or clinical services performed for this company generates personal income paid directly to me or a member of my immediate family
2) I or a member of my immediate family receive(s) personal income for consulting or other services (including CME) for this company
3) I or a member of my immediate family receive(s) personal income for other non-CME services (e.g., advisory services) for this company
4) I am or a member of my immediate family is entitled to or receive(s) personal royalties from this company
5) I have or a member of my immediate family has equity in this company
6) Aggregate Amount of Financial Interest in this company for me and/or a member(s) of my immediate family (total of 1-5 above)
7) Within the last 12 months, I have or a member of my immediate family has been reimbursed by this company for travel in connection with professional duties

In relation to the Company above, please note the following section on Financially Interested Company:

Financially Interested Company: SLHS policy requires that you report any compensation that you receive or Equity or Proprietary Interests that you have in a Financially Interested Company (i.e., the manafacturer of a product that is the subject of your Research project(s), its agent, or a company that is a direct and primary competitor to the manufacturer of the product) even if you purchased the Equity interest. The policy also requires that you disclose whether you hold a fiduciary position with a Financially Interested Company even if the position is unpaid. 

Please answer the following questions:

Compensation
Fiduciary Position
Electronic submission of this form signifies that I have read and understand the Saint Luke’s Health System Policy on Financial Conflict of Interest in Research, ADM 015 and that my questions have been answered to my satisfaction.