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OUHSC Individual Conflicts of Interest Disclosure Form

Returning?

A A A

Click here to access and review the OU Board of Regents Individual Conflicts of Interest Policy.

Please review the OU Board of Regents Individual Conflicts of Interest (COI) Policy linked above and its related policy and guidelines before completing this form.

By answering the questions below, you affirm as an employee of the University of Oklahoma that you have read and agree to comply with the University's Individual COI policy and related guidelines. You also agree to submit an updated COI Disclosure Form if any additional conflicts arise during the year or if disclosures made in this form substantively change. Submission of this form serves as your electronic signature.

First Name

* must provide value

Last Name:

* must provide value

Job Title

OU Network User ID:

* must provide value

Department:

* must provide value

Campus E-Mail Address:

* must provide value

INSTRUCTIONS:

Mark your answer for EACH question below as it relates to you or a member of your family.

The Board of Regents Individual COI Policy defines family as a spouse/domestic partner, parent, child, stepchild, or sibling of an Employee or a member of your (the Employee's) household.

If your answer to any question is YES, you and/or your supervisor will be contacted for more information about possible conflicts and management plan options. If you have any questions, please contact the COI Officer at COIHSC@ouhsc.edu.

SAVE AND RETURN LATER:
If you are unable to answer any of the questions at this time, you may use the 'Save and Return Later' button at the bottom of each page to exit the disclosure form. Your work will be saved and you will receive a code via e-mail to return to your draft form to complete.

Reason for Submitting COI Disclosure (select all that apply):

* must provide value

First time completing a disclosure form since COI training was implemented

New sponsored activity (research, training, or public service)

New professional service (PPP) activity (consulting, speaking, training, etc.)

Additional activity or relationship with a Sponsor/Company

Termination of an activity or relationship with an outside entity or company.

New (unreported) family relationship at OU

Change to a previously disclosed activity

Other

1. Business Relationships and Licensing Agreements

Do you or your family member(s) have any business relationships with a business that:

(a) has a contractual relationship with OU,
(b) provides goods or services to OU,
(c) sponsors or is involved in research activities at OU,
(d) receives referrals from OU, or
(e) pays royalties directly to you?
Note: licensing agreements are considered a business relationship.

* must provide value

Yes

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2. Business Ownership and Equity

Do you or your family member(s) own or have any equity in any businesses whose work is related to the scope of your University responsibilities?

IMPORTANT: Investment vehicles, such as mutual funds and retirement accounts, where the Member does not directly control the investment decisions is not an interest that should be disclosed as per the Regents' Individual COI Policy.

* must provide value

Yes

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3. Nepotism: Family Members Working Together at OU

Do you work in the same area or department as a family member; or do you collaborate with a family member on research or other activities at OU or on any OU campus; or have you been involved in the hiring, supervision, or review of the work of a family member at OU or on any campus at OU?

* must provide value

Yes

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4. Gifts for Personal Use

Have you (as an individual or on behalf of your department) or your family member(s) accepted gratuities, gifts, or special favors from either a person or an entity who is doing business with (or proposing to do business with) the University?

A gift includes but is not limited to food, tickets, trip expenses, cash, and/or gift cards.

* must provide value

Yes

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5. Conflict of Commitment/Outside Jobs and/or Activities.

Do you have additional job(s) or are you involved in any activities, whether at OU or outside of OU, that may create, or appear to create, a conflict of interest/commitment with your responsibilities at OU?

Or

Does your family member (as defined above) have any outside activities or employment that may create, or appear to create, a conflict of interest with your responsibilities at OU?

* must provide value

Yes

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6. Healthcare Industry-Sponsored Activities

Have you or your family member(s) accepted payments from any Healthcare Industry Vendor who does business with OU, or who is attempting to do business with OU?

Examples of Healthcare Industry Vendors include, but are not limited to: suppliers of pharmaceuticals, medical equipment and devices, medical services, research materials, equipment, etc.

* must provide value

Yes

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7. International Activities

Do you or your family member(s) have any international collaborations or appointments, paid or unpaid?

* must provide value

Yes

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8. Multiple Relationships with One Entity

Do you have more than one contract with an external entity, either through the University or as an individual?

Example: Consulting or serving on an advisory board for a company while also conducting a clinical trial for the same company is one example of having more than one contract with a single entity.

* must provide value

Yes

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9. Public Health Service (PHS)-Funded Travel

Are you a PHS-funded employee who has had travel expenses (including transportation, accommodations, meals and/or leisure activities) related to your OU responsibilities, and paid for by a third party outside OU for yourself or a family member for any purpose?

PHS funding agencies include, but are not limited to: National Institutes of Health (NIH), Food and Drug Administration (FDA), Centers for Disease Control (CDC), Indian Health Services (IHS), and more.

* must provide value

Yes

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10. Research and Financial Interests

Are you engaged in sponsored research at OU and have you or your family member received any of the following (related to your OU responsibilities):

(a) payments from an outside entity or foreign government greater than $5,000 in the past 12 months,
(b) any equity in a non-publicly traded entity,
(c) any equity in a publicly traded entity valued greater than $5,000, or
(d) travel reimbursed or paid for/not funded through the University?

* must provide value

Yes

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You have answered 'Yes' to one or more of the 10 screening questions. Additional information about your potential conflict is required. Answer each of the questions that present on the following pages.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.