ࡱ> KNJ 2bjbj$$ 4>F|F|j 008L"$FN T$ B#^5i5HF;T`&j0,#"#;#;55#0 P: Financial Conflict of Interest Disclosure Form for Travel Related to PHS Sponsored Research Investigator First and Last Name  FORMTEXT      ____________________ College(s)  FORMTEXT      _________________ University Email  FORMTEXT      ________________________ Dept(s)/Units(s)  FORMTEXT      ______________________ Investigator Rank FORMTEXT      ____________________ Describe the travel that was sponsored or reimbursed with the entity at present or in the 12 months preceding the date of this disclosure. (Duplicate form as necessary) Name of entity:  FORMTEXT      _________________________________________________________________ Purpose of the trip(s):  FORMTEXT      ____________________________________________________________ ___________________________________________________________________________________ Destination(s):  FORMTEXT      ________________________________________________________________ Date(s):  FORMTEXT      ________________________ Duration (total # of days)  FORMTEXT      _______________________ Aggregate value of the travel expenses (check one below):  FORMCHECKBOX  $0-$4,999  FORMCHECKBOX  $5,000-$9,999  FORMCHECKBOX  $10,000-$19,999  FORMCHECKBOX  $20,000-$100,000 If greater specify: ____________________________________________________________________ Was travel paid for Family Members (spouse, partner, dependent children):  FORMTEXT      _______________  FORMCHECKBOX  Value cannot be determined by reference to public prices or other reasonable measures of fair market value. How does this travel relate to your PHS sponsored research?  FORMTEXT      ___________________________ __________________________________________________________________________  " , . V ^ n p эqэщhdL/jhKhK>*UfHq &hkhJzh&CJ/jthKhK>*UfHq &hUS:4jhKhK>*UfHmHnHq &u/jhKhK>*UfHq & hKhK>*fHq &)jhKhK>*UfHq &h&hM h(hz|CJh(hz|5J  r t > @ |~gdfi &dPgdz|gdz|  . 2 4 H T V X l n p z |  2 4 p r ЯĎЯrne]Yh*h&56>*hJzhJzCJhJz/jhKhK>*UfHq &hKhJzh&CJ/j\hKhK>*UfHq & hKhK>*fHq &hfih&hVhk)jhKhK>*UfHq &4jhKhK>*UfHmHnHq &u!r t 8 < > @ p r ͵ޚuޚlT/j,hKhK>*UfHq &hJzh&CJ /jhKhK>*UfHq &hJzh&CJhUS:4jhKhK>*UfHmHnHq &u/jDhKhK>*UfHq & hKhK>*fHq &)jhKhK>*UfHq &h&hnVh&CJ &(<>@JL|~,68Tв̖в~yumi^miuimijhUhjhUhfi h&6/jhKhK>*UfHq &h6//jhKhK>*UfHq & hKhK>*fHq &hJzh&CJh&)jhKhK>*UfHq &4jhKhK>*UfHmHnHq &u#TVXvxHJNPdfhrtpU4jhKhK>*UfHmHnHq &u/jZhKhK>*UfHq & hKhK>*fHq &)jhKhK>*UfHq & hahahahh>h>h>CJh&jhUhfijrhUhjhUjhU!jl&&&&'' (b*T,..///0gd & Fp^`pgdgdfigdfigd@ ^`gdwY^gdfi "$&02jl&&&&@&B&ϺvtkdM-jhKhK>*CJUfHq & h Wh WhnVhfiCJU4jhKhK>*UfHmHnHq &u/jDhKhK>*UfHq & hKhK>*fHq &)jhKhK>*UfHq &h@h>h@CJ hfijhwYUhwYjhwYUh>h>CJ _________ Additional Comments:  FORMTEXT      ________________________________________________________________________ I affirm that: " The above information is true to the best of my knowledge. I have completed the Financial Conflict of Interest Disclosure Form. I must disclose all sponsored or reimbursed travel (42 CFR 50.605) within 30 days if not previously reported and will update the Financial Conflict of Interest Disclosure Form within 30 days of acquiring or discovering a new or a change in any of my financial or fiduciary relationships. " I have read the University s Policy on Conflicts of Commitment and Interest and external activities disclosed here have been disclosed and approved on my Report of Non-University Activities (RNUA) form (if I am required to submit the RNUA form.) " If the disclosed relationship with the external entity is determined by the University to be a Financial Conflict of Interest (FCOI) related to the research question of my sponsored research, then I must have an approved University conflict management plan prior to expenditure of funds related to the research project.  FORMTEXT      _____________________________________  FORMTEXT      _____________ Signature Date Send completed form to: Vice Chancellor of Academic Affairs and Provost, c/o Grants, Contracts, and Research Administration, MS PAC 525.     University of Illinois at Springfield Office of G.C.&R.A. 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