Research Conflict of Interest Disclosure Statement

This form is to be completed in connection with the Saint Luke’s Health System Policy on Conflicts of Interest in Research, RES-052, by all Investigators responsible for Sponsored Research activities, regardless of title or position, who are responsible for the design, conduct, or reporting of Research or proposals for funding of Research, in which an Entity of Saint Luke’s is engaged or is reviewed by the Saint Luke’s Health System (SLHS) Institutional Review Board (IRB). Potential conflicts may be related to Conflicts of Commitment or Financial Interests, as defined by the policy.

The disclosure form must be completed based on the time points specified per policy:

  • At least 30 days prior to submitting an application to the IRB for consideration of a Sponsored Research project, and
  • Annually thereafter while participating in Research, and
  • Within 30 days of discovering or acquiring a new Significant Financial Interest or Significant Conflict of Commitment, and
  • For PHS-funded Research, the form will be submitted at the time of the application for PHS funds, and
  • New Investigators joining the Research team of an ongoing Sponsored Research project, within 30 days of their involvement in the project.

The SLHS IRB, Office of Research Services, and Research Conflict of Interest Committee will protect the confidentiality of private investments and personal finances and will request information related only to potential conflicts that might influence the objectivity of Research being conducted.

Your answer(s) to the questions do not imply that any interest you disclose is improper or impermissible. However, failure to report a potential conflict 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 potential conflict and submit updated information as changes occur.

Please direct questions regarding this form to the Ethics, Compliance & Privacy Department at

Prefer the paper version? Download the Research Conflict of Interest Disclosure Form (PDF) and submit it to

If you are disclosing due to a new IRB application, or joining an ongoing Sponsored Research project, supply the protocol title and the name of the study sponsor:
Do not include travel reimbursed or sponsored by US federal, state or local governmental agencies, US institutions of higher education or US research institutes affiliated with institutions of higher education, or academic teaching hospitals and medical centers.

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I hereby affirm that the information I have provided on this form is complete and accurate to the best of my knowledge.