Research Conflict of Interest Disclosure Statement Form

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. 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:

  1. Annually. Investigators participating in Research must submit an updated RCOI Disclosure Form at least annually, even if attesting to no actual or potential conflicts. The updated disclosure will include any new information that was not disclosed initially or in any subsequent disclosure of SFIs and SCOCs, and will include updated information regarding any previously disclosed SFI or SCOC (e.g., the updated value of a previously disclosed equity interest). 
  2. Initiating Sponsored Research. Investigators with a potential or actual SFI or SCOC, that is potentially related to their Institutional Responsibilities and the proposed Sponsored Research project, must submit an RCOI Disclosure Form prior to submitting the project for IRB consideration.
  3. Joining Sponsored Research. Investigators with a potential or actual SFI or SCOC, that is potentially related to their Institutional Responsibilities and the ongoing Sponsored Research project, must submit an RCOI Disclosure Form prior to their involvement in the project.
  4. Ad Hoc Disclosures. All Investigators must submit an RCOI Disclosure Form within 30 days of discovering or acquiring a potential or actual SFI or SCOC that is potentially related to their Institutional Responsibilities.
  5. PHS-funded Research. Investigators must submit an RCOI Disclosure Form no later than the time of application for PHS funds. 

You must re-submit this form with 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 the Research Conflict of Interest Disclosure Form (PDF) and submit it to Compliance@Saint-Lukes.org.

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:
Disclosures should include salary or payments for services from any publicly or non-publicly traded entity, whether foreign or domestic, and any foreign institution.
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.
I hereby affirm that the information I have provided on this form is complete and accurate to the best of my knowledge.