ࡱ> `b__ Dbjbj .Tbb ff8 lx\B)ZZZZIa<m(o(o(o(o(o(o($2+-`(i=II==(ZZ(=FZZm(=m(r&T'Z4$Fg&Y()0B)u&D.D.''&D.9' =======((===B)====D.=========f : Subrecipient Disclosure of Financial Conflict of Interest Form Name/Organization:  FORMTEXT      Investigator Name:  FORMTEXT      Authorized Official:  FORMTEXT      Contact Information:  FORMTEXT      Address:  FORMTEXT      Phone:  FORMTEXT      Phone:  FORMTEXT      Email:  FORMTEXT      Email:  FORMTEXT      Additional Investigators:  FORMTEXT       UIS Department:  FORMTEXT       Contact Person:  FORMTEXT      Office Address:  FORMTEXT      Mail Stop:  FORMTEXT      Phone:  FORMTEXT      Email:  FORMTEXT       Do you (your spouse or dependent children) have a significant financial interest in a publicly traded entity that, when aggregated, exceeds $5,000? Please include the value of any equity interest** as of the date of this disclosure to any remuneration* received from the entity in the twelve month preceding this disclosure.  FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, provide name of business entity):  FORMTEXT       Do you (or your spouse and/or dependent children) have the following significant financial interests in a non-publicly traded entity? Aggregated exceeding $5,000 Remuneration (including equity interest)?  FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, provide name of business entity):  FORMTEXT       Any equity interest?  FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, provide name of business entity):  FORMTEXT       Have you (your spouse or dependent children) received income in excess of $5,000 during the twelve months preceding this disclosure that is related to intellectual property rights and interest (e.g., patents, copyrights)?  FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, provide name of business entity):  FORMTEXT |~     H J L ` b d n p r ĵą܁ĵjąĵSą܁,jxhxhjUfHq &,jthxhjUfHq &hOOh1jhxhjUfHmHnHq &u,jhxhjUfHq &hxhjfHq &&jhxhjUfHq &hj hOOhhOOhhDhxbhh 5CJhhxb5CJ ~ r Vkd$$Ifl 0$$ t0 %644 lapytx$Ifgdnl gdxb$a$gdxb   $ & ( 2 4 8 D F H \ ^ ` j l n z 즢݋즇p즇Y즇,jhhxhjUfHq &,jdhxhjUfHq &hOOh,jhxhjUfHq &hj hOOhhOOh1jhxhjUfHmHnHq &u,jhxhjUfHq &hxhjfHq &&jhxhjUfHq &" 6 vcc$Ifgdnl kd`$$Ifl 0$$ t0 %644 lapytx6 8 n vcc$IfgdOOhl kd$$Ifl 0$$ t0 %644 lapytxz ~    * , . 8 : > @ B b d 袞ه袞plhdP&jhxh>UfHq &h>hDh ,jThxhjUfHq &,jhxhjUfHq &hOOh hOOhhOOh1jhxhjUfHmHnHq &u,jhxhjUfHq &hxhjfHq &&jhxhjUfHq &hj < vcc$Ifgdnl kdP$$Ifl 0$$ t0 %644 lapytx< > @ B vqq^^$Ifgdxbl gdxbkd$$Ifl 0$$ t0 %644 lapytxd x z |     2 ŬŬŨyjSy:y1jhxh=UfHmHnHq &u,jhxh=UfHq &hxh=fHq &&jhxh=UfHq &h=,jhxh>UfHq &h>1jhxh>UfHmHnHq &u&jhxh>UfHq &,jZhxh>UfHq &hxh>fHq &  \ vcc$Ifgdxbl kdF$$Ifl 0$$ t0644 lapytx2 4 6 J L N X Z l n p | َwsogoso_[hs/?jhs/?UhEhE5hEhH<,j hxh=UfHq &,jR hxh=UfHq &h>1jhxh=UfHmHnHq &u,jL hxh=UfHq &hxh=fHq &&jhxh=UfHq &h= \ ^ vcc$Ifgdxbl kd $$Ifl 0$$ t0644 lapytx $vqe\S\G  & Fh^hgdE^gds/?h^hgdE  & Fh^hgdH<gdH<kd> $$Ifl 0$$ t0644 lapytx  &vijĀ||t|plphp`\Q`j, hUTUhUTjhUTUhEh_uh~hEhE5hE4jhs/?hs/?>*UfHmHnHq &u/j hs/?hs/?>*UfHq & hs/?hs/?>*fHq &)jhs/?hs/?>*UfHq &jB hs/?Uh:/hs/?jhs/?Uj hs/?U$&88N8P8R8T8V8$<&<h^hgd  & Fh^hgd^gdgdHXa  & Fh^hgdE^gd ^gd~gd~ & Fgd~gdEtv &(*̻̈yn̻jhUTUjhUTUh 4jh<h<>*UfHmHnHq &u/jh<h<>*UfHq & h<h<>*fHq &)jh<h<>*UfHq &j hUTUjhUTUh:/h~hUT$#$ҷҳyhP/jh<h<>*UfHq & h<h<>*fHq &j\hUTUh:/hjhUTUhUTjhUTUhEh4hHXahEh 4jh<h<>*UfHmHnHq &u)jh<h<>*UfHq &/jrh<h<>*UfHq &      Prescribe:  FORMTEXT       Has any organization sponsored or reimbursed you for any travel you have taken that is related to your work for the University of Illinois at Springfield? Note: you are not required to disclose to 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.  FORMCHECKBOX  No  FORMCHECKBOX  Yes (if yes, provide information below) Name of sponsor/organizer:  FORMTEXT       Purpose:  FORMTEXT       Destination:  FORMTEXT       Duration of trip:  FORMTEXT       Additional details about reported financial interests:  FORMTEXT       Investigator Certification I certify, to the best of my knowledge, that the information reported herein is complete and accurate.  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