Potential Financial Conflict of Interest (FCoI) and Conflict of Commitment (CoC) Disclosure Form

Faculty and staff at Miami are bound by Miami Policies to manage issues regarding perceived or real Financial Conflict of Interest (FCoI) and Conflict of Commitment (CoC).

An FCoI/CoC disclosure must be completed by ALL COVERED INDIVIDUALS listed on a proposal to a federal agency PRIOR TO SUBMISSION. These covered individuals include principal and co-principal investigators, all listed senior personnel or other key personnel, research associates/assistants, postdoctoral fellows, named graduate students or undergraduate students, and the same list of covered individuals for each subrecipient organization.

In addition, all of the covered individuals listed above must also complete the CITI COI-PHS-Basic Course every four years for most (every two years for DoE). A new disclosure is required within 30 days of discovering or acquiring a new potential FCoI/CoC.

EXCLUSIONS: This does not apply to any salary, royalties, or other remuneration paid by Miami University if you are currently employed or otherwise appointed by Miami University; income from seminars, lectures, or teaching engagements sponsored by a United States federal, state, or local government agency, an institution of higher education, an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education; or income from service on advisory committee or review panels for such agencies or other entities.

NOTE: The General Counsel's Office administers an annual COI certification that is separate from the Public Health Services' (PHS) requirement for FCoI/CoC disclosure. 

Responses to this form will be kept confidential.

Questions about FCoI/CoC may be directed to Amy Balk at
 balka@miamioh.edu.

Key terms:
Non-US Entity = foreign government or foreign institution of higher learning.
Family = Spouse or dependent children.
Conflict of Commitment = A situation in which a covered individual accepts or incurs conflicting obligations, whether foreign or domestic, between or among multiple employers or other entities and may include conflicting commitments of time and effort, including obligations to dedicate time in excess of institutional or DOE policies or commitments. (2 CFR 910.122)

Sign in to Google to save your progress. Learn more
Email *
Your Name: *
Your Miami University Unique ID (publicjq):
Are you submitting an initial disclosure or a change to your current disclosure? *
Provide the Cayuse record number. *
Is this disclosure for a project funded by the U.S. Department of Energy? *
Are there any restrictions on the release of publications resulting from this project?
*
Are non-US government entity(ies) involved in any phase of the project? *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Google Apps @ Miami University.

Does this form look suspicious? Report