The University of Arizona

Conflict of Interest Disclosure Form for Subcontractors, Consultants, and Collaborators

Please enter the date on which you completed the required University of Arizona conflict of interest training.  By entering a date, you are certifying that you completed the required training.  If you have not completed the required conflict of interest training, please do not complete this form until after you have done so.  For instructions on how to complete the training, please contact the University of Arizona's Conflict of Interest Office at (520) 626-6406 or coi@arizona.edu.

1. Travel

Is the prime sponsor on your subaward from the University of Arizona any of the entities listed below? The prime sponsor is the sponsor on the award to the University of Arizona, which results in the subaward to your institution.  Contact your subaward team member at if you are unsure.  

If you responded "Other" above, provide the name of the project's Prime Sponsor.
Prime Sponsor for Travel

Under the PHS/NIH conflict of interest regulations, investigators must disclose the occurrence of any reimbursed or sponsored travel (i.e., that which is paid on behalf of the investigator and not reimbursed to the investigator so that the exact monetary value may not be readily available), related to their institutional responsibilities; provided, however, that this disclosure requirement does not apply 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.

Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".

2. Remuneration

(Complete a separate disclosure for each entity)

Entity One - Remuneration
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
Second Entity - Remuneration
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".

If you have more than two (2) entities to disclose, please contact the Conflict of Interest office at coi@arizona.edu.

3. Ownership Interests

(Complete a separate disclosure for each entity)

Entity One - Ownership Interests
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
If you responded "Other", please provide a short description of the remuneration received.
Second Entity - Ownership Interests
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
If you responded "Other", please provide a short description of the remuneration received.

If you have more than two (2) entities to disclose, please contact the Conflict of Interest office at coi@arizona.edu.

4. Intellectual Property

(Complete a separate disclosure for each entity)

Entity One - Intellectual Property
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
Second Entity - Intellectual Property
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".

If you have more than two (2) entities to disclose, please contact the Conflict of Interest office at coi@arizona.edu.

5. Role

(Complete a separate disclosure for each entity)

Entity One - Role
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
(To select multiple options, press and hold "Ctrl" key)
If you responded "Other" above, please describe the office or position held.
Second Entity - Role
Select the value of the significant final interest. If the value of the interest cannot be readily determined through reference to public process or other reasonable measures of fair market, select "No Fair Market Value".
(To select multiple options, press and hold "Ctrl" key)
If you responded "Other" above, please describe the office or position held.

If you have more than two (2) entities to disclose, please contact the Conflict of Interest office at coi@arizona.edu.

6. If you answered "Yes" to any of questions 1-5, above, please complete the following items. If you answered "No" to questions 1-5, above, scroll to item 7 at the bottom of this form and submit your disclosure.

If you responded "Other", above, please provide a short description of your role.

Does the research to be conducted in this subcontract involve the testing of any drugs, devices, assays, biologics, software, equipment, products, procedures, materials or other technology belonging to, or with significant potential impact on, your significant financial interest?

7. Certification

I certify that:

  1. I have completed the University of Arizona's conflict of interest training;
  2. I understand the University of Arizona's conflict of interest disclosure requirements, including annual certification requirements;
  3. I have used all reasonable diligence in preparing this statement and that it is true and correct;
  4. I will comply with any conditions or restrictions imposed by the University of Arizona to manage any Financial Conflicts of Interest; and
  5. Should my outside financial or personal interests, or those of my Family Members, change in a way that results in a different answer to any of the questions asked in this report, I agree to submit a revision.

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