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// Medical Professionals // Research // Conflict of Interest Form

Research Conflict of Interest Disclosure Statement

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Conflict of Interest Form
Human Research Protection Program

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 Compliance@Saint-Lukes.org.

Prefer the paper version? Download the Research Conflict of Interest Disclosure Form (PDF) and submit it to Compliance@Saint-Lukes.org.

Last Name

First Name

This submittal is for (check all that apply):

Annual disclosure

New IRB application

New Investigators joining the research team of an ongoing sponsored research project

Newly acquired conflict

Updated disclosure

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:

Protocol Title

Study Sponsor

In the 12 months preceding this disclosure, have you or your Family received, from any publicly traded entity, any salary or other payments for services that exceeds $5,000 in total?

Yes

Name of person who received the payments:

Your relationship to such person (self or Family member):

Name of the entity:

Nature and approximate monetary value of the payments:

During the 12 months preceding or as of the date of this disclosure, do you or your Family hold, in any publicly traded entity, any equity interest that exceeds $5,000?

Yes

Name of person who received the payments:

Your relationship to such person (self or Family member):

Name of the entity:

Nature and approximate monetary value of the payments:

During the 12 months preceding the date of this disclosure, have you or your Family received any income related to intellectual property rights and interests?

Yes

Name of person who received the payments:

Your relationship to such person (self or Family member):

Name of the entity:

Nature and approximate monetary value of the intellectual property rights and interests and related income:

During the 12 months preceding the date of this disclosure, have you or your Family (a) served in an executive position in a for-profit business that engages in commercial or Research activities of a biomedical nature; or (b) served in a fiduciary role for a for-profit business that engages in commercial or Research activities of a biomedical nature?

Yes

Name of person who served in such role:

Your relationship to such person (self or Family member):

Name of the business:

Nature of the role:

For PHS-funded Investigators only: During the 12 months preceding the date of this disclosure, have you undertaken any reimbursed or sponsored travel related to your Institutional Responsibilities?

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.

Yes

Not applicable

Purpose of the trip:

Identity of the sponsor/organizer:

Destination:

Duration: