consultant conflict of interest declaration

					Stanford University                          Consultant                                               RPT-I2
Research Compliance Office           Conflict of Interest Declaration

          Any potential consultant must disclose a conflicting interest in a project to the IRB
          staff, but may not vote on the project. If a consultant discloses a conflict of interest,
          he/she cannot consult on the project.

          A conflicting interest for a consultant generally includes the following. The aggregate
          interest of the consultant and his/her immediate family is considered.
          1) Participation in a project (consultant is listed as an investigator on the project or
              is a member of the research team);
          2) Supervision of a project (consultant is a faculty sponsor of the Protocol Director,
              or a situation in which any investigator must report to or is under the professional
              supervision of the consultant);
          3) Financial interest if it involves:
             (a) receiving more than $10,000 annually as salary, consulting income, or other
                 compensation related to the research;
             (b) having an equity interest (including stock or stock options) that exceeds
                 $10,000 or that represents more than 5% of the company sponsoring the
             (c) having an ownership interest (including patent, trademark, or copyright
                 interest) in the drug/product/technology that is the subject of the research
                 project; or
             (d) receiving or expecting to receive compensation with a value that may be
                 affected by the outcome of the study;
          4) Personal relationship with investigator (consultant has an immediate family
             relationship or other close personal relationship with the investigator);
          5) Fiduciary relationship to sponsor (consultant serves as an executive to a company
             sponsoring the research or serves on the company’s board of directors);
          6) Other nonfinancial interests that may be conflicting interests, such as if
             (a) consultant has an interest that he/she believes conflicts with the consultant’s
                 ability to review a project objectively; or
             (b) the consultant is in direct competition with the investigator for limited
                 resources, funding, sponsorship, or research subjects, or the consultant is
                 considered a personal or professional adversary of the investigators
          7) Any other reason for which the consultant believes he/she has a conflicting
               interest with the research.

          I am not involved in, and have no other conflicting interest in the following research
          on which I have been asked to consult:

          Protocol ID#:

          PD:                                                 Sponsor:

          Protocol Title:

          ___________________________                         _______________________
                             Signature                                         Date
                      Name (please print)

File:RPT03I02   rev2 08/08                         1 of 1

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