Significant Financial Interest Disclosure Form

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The College uses your responses on this form to determine whether any of your significant financial interests represent a financial conflict of interest (pursuant to the Financial Conflict of Interest policy). Please refer to the Haverford College Financial Conflict of Interest Policy for more information.

Name * First Last
Department *
Email *
Title of grant proposal *
1. Significant Financial Interest (see Policy for definition). Do you, your spouse, or dependent children have a significant financial interest that: (1) would reasonably appear to be affected by your research; and (2) is in an entity or entities whose financial interests would reasonably appear to be affected by your research?
a. Salary or other payment for services (e.g. consulting fees, honoraria or paid authorship) *
Yes No
If yes, please describe each instance of salary or payment for services and dollar amounts:
b. Equity Interests (e.g. stock, stock options, or other ownership interests) *
Yes No
If yes, please describe each equity interest, including value of stock or ownership interest:
c. Intellectual Property Rights (e.g. patents, copyrights, and royalties from such rights) *
Yes No
If yes, please describe each instance of intellectual property rights:
d. Sponsored or reimbursed travel (i.e travel paid on your behalf): *
Yes No
If yes, please describe each instance of sponsored or reimbursed travel and dollar amount:
e. Other
Yes No
If yes, please describe, including the degree of commitment:
2. Are you engaged in Government Consultanships: Please describe all such relationships: *
Yes No
3. Have you engaged in an extramural program related to your research with either a government agency or private firm within the past year? *
Yes No
If yes, indicate name of each such program and agency/firm:
4. Other Pertinent Information: Please use the space below to provide any further information or explanatory comments:
ACKNOWLEDGEMENT AND ELECTRONIC SIGNATURE REQUIRED:
By checking this box, I confirm that I have reviewed and understand Haverford College’s Financial Conflict of Interest Policy. The above information is complete and accurate to the best of my knowledge. I agree to update this disclosure during the period of the award as new reportable significant financial interests are obtained. *
I agree I do not agree
Date * / MM / DD YYYY