Do you *OR anyone* involved in this research who has responsibility for the design, conduct or reporting of the research have a relationship or receive payment for services or have stock or stock options in the proposed sponsor, vendor(s), or subcontractor(s) or in a company that would be interested in the study results but is not sponsoring the study?

How to Determine Disclosure Requirements

What must be disclosed?

1. Any relationship such as unpaid consultant, founder, or employee;
2. Payment for services such as consulting, service on an advisory board, or giving talks;
3. Stock or stock options;
4. Gift funds.

Who must disclose?

1. Principal investigator*
2. Any other participant* in the research who has responsibility for design, conduct, or reporting of the research, or in other words anyone who has independent responsibility for the research or research results;
   * (this includes spouse/domestic partner, and dependent child(ren);

When must it be disclosed?

1. When the relationship or financial interest is related to the company sponsoring the study (i.e. consulting for a company sponsoring the research);
2. When the relationship or financial interest is indirectly related to the study:
   1. the company is supplying a product being studied;
   2. the study will be purchasing materials, supplies or equipment from a company in which there is a relationship;
   3. or the results of the research would be of interest to the company in which there is a relationship;
3. At application or renewal, or when there is a new reportable interest.

What happens?

All reported financial interests will be reviewed by the appropriate Dean's office or designated school committee to determine whether action is necessary to manage, reduce or eliminate a conflict of interest. Additional information @  http://www.stanford.edu/dept/DoR/Resources/coi.html.

FACULTY CERTIFICATION

I certify that the statements herein are true, complete and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application. Furthermore, I certify that I will direct this project in compliance with Stanford University policies, with the terms and conditions of Stanford's agreement with the sponsor and with all applicable laws and regulations, and I will uphold the responsibilities of PIship.

Signature Date

DEPARTMENT APPROVALS

I have reviewed and approve the financial commitments for this proposal, including any cost sharing, any salary in excess of the sponsor's salary cap, or infrastructure charges. I have also reviewed and approve the space commitments. I have reviewed the proposed/reported effort and confirm it is accurate.