Office of Research and Sponsored Programs
Financial Conflict of Interest Assurance and Disclosure Form
This form is used to disclose any financial relationships with entities involved in or related to active, proposed, or planned externally sponsored projects and programs
at UL Lafayette or to report changes in previously disclosed relationships or activities. If you are applying for an NSF or PHS funded grant, each investigator
must complete a copy of this form to be submitted to ORSP along with your proposal and Internal Proposal Approval Form.
Project Sponsor: NSF NIH or other PHS Other Federal State Corporate Non-Profit Other:
Role in Project: PI Co-PI Other Key Personnel
1. Aside from your salary or royalties that would be earned from possible inventions resulting from this project, will you or a family
member derive any other economic benefits from the project? Yes No
If yes, what is the estimated benefit?
2. Do you and/or a family member currently have or have had in the past three (3) years any financial interest related to an entity
involved with the above named active, proposed, or planned externally sponsored project as described in questions 3-6 below?
Family Member includes spouses, parents, parents of spouses, siblings, spouses of siblings, children, and spouses of children.
Yes (choose this response if you can answer “yes” to any of questions 3-6. Then enter information about the entity and answer questions
3-6 below. If you have reportable interests in more than one entity, attach additional forms as needed.)
No (choose this response if the answers to questions 3-6 are “no.” Then please skip to the Investigator Certification. )
Please answer the following questions if you and/or a family member have or have had in the past three (3) years any of the relationships
listed below with an entity involved in an active, proposed, or planned externally sponsored project at UL Lafayette:
Name of Entity:
Address of Entity:
Principal Type of Business/Activity:
Do you and/or a family member currently or have in the past three (3) years:
3. Serve (Served) as a director, officer, partner, trustee, or employee of the entity? Yes No
4. Serve (Served) as a consultant or contractor to the entity? Yes No
5. Have (Had) a combined investment of $10,000 or more in the entity? Yes No
6. Hold (Held) a combined equity position of 5% or more in the entity? Yes No
7. Have (Had) a controlling interest in the entity (25% or more interest)? Yes No
If yes, how is the entity related to or involved in an active, proposed, or planned sponsored project?
Subcontractor Funding Agency Third Party Contributor Other (please describe):
All investigators completing this form must read and sign this section. Once signed, please return the form to ORSP.
I agree to update this disclosure either on an annual basis, or as new reportable financial interests are obtained.
I agree to cooperate in the development of a resolution plan to address any actual or potential conflicts of interests regarding this project that may be identified in
this disclosure statement or that may arise in the future.
I agree to comply with any reasonable conditions or restrictions imposed by UL Lafayette to manage, reduce, or eliminate actual or potential conflicts of interest,
including forfeiture of the award if deemed necessary.
I understand that actual or potential financial conflicts of interest may be reported to funding agencies if required by state or federal regulations or by funding
Print/Type Name Signature Date
I have reviewed the above and believe that no substantial conflict of financial interest exists, or, if one does exist, that it is possible to develop and execute a
resolution plan to manage, reduce, or eliminate any actual or potential conflict of interest.
Vice President for Research and Graduate Studies Date