ASSURANCE FORM FOR SUBGRANTEES

Pursuant To Haverford College Financial Conflict Of Interest Policy For Scientific Research

Dear Administrator: Federal regulations require that subgrantees working with Investigators who have received federal research funds must themselves be in compliance with federally mandated conflict of interest provisions. Therefore, to ensure such compliance, Haverford College seeks the following assurances from the subgrantee’s employer.
1. Names of Subgrantee and Subgrantee’s Employer
Name of Subgrantee: * First Last
Name of Subgrantee’s Employer: *
2. Subgrantee’s employer represents that:
A. Said institution has adopted a conflict of interest policy that: 1) is in compliance with all applicable federal conflict-of-interest regulations, including 42 C.F.R. § 50.604; and 2) requires any conflicts identified to be managed, reduced or eliminated. (Please attach a copy of employer’s conflict of interest policy.) *
B. The Subgrantee has complied with the employer’s conflict of interest
policy with regard to the research described below: *
3. Conflict Resolution
Please describe any conflicts that exist with regard to subgrantee’s work on the project described in paragraph 2B above, and the steps that were taken to manage, resolve or eliminate the conflict(s). *
4. Administrator’s Contact Information
Name of Administrator in charge of Employer’s Conflict of Interest Program: * First Last
Title of Administrator in charge of Employer’s Conflict of Interest Program: *
Administrator’s Mailing Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Administrator's E-Mail Address *
Administrator’s Telephone Number * - ### - ### ####
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 I Do Not Agree
Date * / MM / DD YYYY
If subgrantee’s employer cannot make the representations required in section 2, subgrantee must make arrangements to be bound by Haverford College’s own conflict of interest policy.

ASSURANCE FORM FOR SUBGRANTEES

ASSURANCE FORM FOR SUBGRANTEES

1. Names of Subgrantee and Subgrantee’s Employer

2. Subgrantee’s employer represents that:

3. Conflict Resolution

4. Administrator’s Contact Information

ACKNOWLEDGEMENT AND ELECTRONIC SIGNATURE REQUIRED:

If subgrantee’s employer cannot make the representations required in section 2, subgrantee must make arrangements to be bound by Haverford College’s own conflict of interest policy.