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(OLD) Financial Conflict of Interest Disclosure Statement: Policy CPM 11-96

Please complete this Disclosure Statement after reviewing, and with reference to the Rady Children's Hospital Financial Conflict of Interest Related to Public Health Service Sponsored Research Policy (CPM 11-96).

To access this policy, please 'click' here: Financial Conflict of Interest Related to Public Health Service Sponsored Research Policy (CPM 11-96).



 
*This question is required.
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1. Within the past twelve (12) months, have you or members of your immediate family, i.e., spouse, domestic partner or dependent children, acquired "significant financial interests*": 

a) That directly affect or reasonably appear to affect your research, instruction or scholarly activities funded or proposed for funding?

b) In entities whose financial interests directly or reasonably appear to affect your research, instruction or scholarly activities? *This question is required.

Significant financial interests*: Financial interests valued in excess of $5,000 or which equal or exceed 5% ownership (i.e, as the actual or beneficial owner of more than five percent (5%) of the voting stock or controlling interest), for any one enterprise or entity when aggregated for you and your immediate family.

Excludes: 1) Salary, royalties or other remuneration from the hospital; 2) Income from seminars, lectures, or teaching engagements sponsored by public or non-profit entities; or 3) Income from service on advisory committees or review panels for public or non-profit entities.
2. Within the past twelve (12) months, have you or members of your immediate family had an employment, consulting, or other financial relationship with:

a) An external sponsor of your hospital research, instruction or scholarly activities?

b) A company that does business with Rady Children's?

c) An outside organization contributing gift funds to Rady Children's that are under your control or of direct benefit to your research, instruction or scholarly activities? *This question is required.
3. Intellectual Property Rights and Interests:

Have you received any payments in excess of $5,000 during the twelve months preceding this disclosure for any intellectual property rights and interests (e.g, patents, copyrights assigned or licensed to a party other than Rady Children's Hospital? *This question is required.
4. Travel Reimbursement:

Has any organization sponsored or reimbursed you for any travel you have taken that is related to your work for Rady Children's Hospital?

NOTE: You are not required to disclose 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. *This question is required.
Certification: In submitting this form, I certify that the above information is true to the best of my knowledge, and that I am in compliance, to the best of my knowledge, with federal law, state law and all Rady Children's Hospital policies related to conflicts of interest.

I agree that my typed name shall have the same force and effect as my written signature.

This form must be updated and re-submitted within 60 days of any change in status of financial interests. Example: when financial interests in a single entity increase to the $5,000/5% threshold.
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