RESEARCH CONFLICT OF INTEREST DISCLOSURE

INSTRUCTIONS

The principle investigator and ALL co-investigators are required to complete a Conflict of Interest Disclosure.

This document must be signed by hand.

Spellcheck will not work on this application. Proofread before submitting.

Submit completed form to the IRB office via:

Email – nobles.penny@navicenthealth.org (as scanned .pdf file)

Mail – Medical Center of Central Georgia, Institutional Review Board, 777 Hemlock Street, MSC 113, Macon, Ga 31201

Study Title:

NO Conflict

The Investigator whose name is listed immediately below certifies that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, related to this research.

Investigator Name (printed)	Investigator Signature

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Disclosure of Conflict

The investigator whose name is listed immediately below reports the following details of affiliation or involvement in an organization or entity with a financial or non-financial interest related to this research project. Please specify the nature of the conflict.

Nature of Conflict:

Investigator Name (printed)	Investigator Signature

CONFLICT OF INTEREST

1. What is a conflict of interest?

Actions or situations that might influence, or be perceived as being capable of influencing, an individual’s judgment regarding his/her obligations to the conduct of the research by considerations of personal gain (or gain to immediate family) whether financial or otherwise.

2. What is a potential conflict of interest?

A potential conflict is a situation that may develop into an actual conflict of interest.

3. What is an appearance of a conflict of interest?

A reasonable person would believe that a situation exists where official duties or professional judgment would be compromised. The mere appearance of a conflict may be as serious and potentially damaging as an actual conflict.

4. If I am involved in a conflict of interest situation does that mean I’m doing something wrong?

Not necessarily. It is not an accusation and does not necessarily imply that an individual’s judgment has been comprised.

5. What is considered a family member?

A spouse, child, stepchild, parent, sibling, or domestic partner.

6. How do I determine if I have a conflict of interest?

You should ask yourself if the situation would interfere or even have the appearance of interfering with the independent judgment you should show when performing your professional duties. If you knew someone had a similar conflict would you trust his or her judgment? In many cases only the individual will be aware of a conflict or potential conflict, so it is very important to inform the Corporate Compliance Officer of a potential or actual conflict of interest.

7. Why do we have to be concerned about conflicts of interest?

There are laws that prohibit certain conflict of interest situations. In addition, conflicts of interest may adversely affect public perception of you and the organization, as well as adversely affect internal perception.

8. What may happen if there is a conflict of interest and it is not revealed or managed appropriately?

Failure to disclose a conflict in violation of Central Georgia Health System’s policy could lead to dismissal as a research investigator. Certain conflict of interests may lead to an investigation by state or federal officials, which in turn may lead to criminal prosecution or a civil legal action.

10. I own stock in a publicly traded pharmaceutical company. Is this a conflict of interest?

Investments in publicly traded companies are not considered conflicts of interest unless your activities could have other than an inconsequential effect on the value of the stock of such company.