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Disclosure Forms for Consulting Activities
草榴社区
Principal Investigator Disclosure Of External Affiliations
(To be appended to Extramural Funding Proposal Coordination Sheet)
Faculty Member抯 Name FORMTEXT School/College FORMTEXT
Title/Rank FORMTEXT Date FORMTEXT
Title of Proposed Sponsored Project FORMTEXT
Name of Funding Sponsor/Other FORMTEXT
Proposed Period of Project: Beginning Date FORMTEXT Ending Date FORMTEXT
Please answer all questions. If yes is answered to any question, please describe the nature and extent of the affiliation and attach to this document.*
1. Will acceptance of this sponsored program interfere with meeting your obligations to students, faculty colleagues or UAH?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
2. Do you or will you have any affiliation with the proposed external funding organization, a subcontractor or vendor that would or could interfere with meeting your obligations to students, faculty colleagues or UAH?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
3. Other than as described in the proposal, do you plan to involve students in any capacity in the proposed work for this external funding organization during the course of this sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
4. Do you or any members of your immediate family participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the external funding organization, a subcontractor or vendor or of any organization providing goods and/or services for the sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
5. Do you or any member of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or controlling interest of the external funding organization, a subcontractor or vendor or any organization providing goods and/or services for this sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
Answer questions 6 and 7 if this is a government sponsored project.
6. Have you or any member of your immediate family received significant income from a subcontractor or vendor or organization providing goods and/or services for this proposed sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
7. Do you or any member of your immediate family anticipate receiving significant income from a subcontractor or vendor or any organization providing goods and/or services for this proposed sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
* Any answer of 搚es� on the questions posed will elicit review by the appropriate dean and if indicated be forwarded with dean抯 comments/recommendations to the Professional Review Committee.
CERTIFICATION**
I hereby certify that I have read and understood the University of Alabama in Huntsville Conflict of Interest policy. Furthermore, should any potential or actual conflict of interest arise during the conduct of the proposed research, I acknowledge that I have an obligation to disclose immediately such conflicts in writing to the chair and dean and seek resolution.
Faculty Member Signature Date
FORMCHECKBOX Approved
FORMCHECKBOX DisapprovedChair SignatureDate
FORMCHECKBOX Approved __________________________ _________
FORMCHECKBOX DisapprovedDean Signature Date** Each principal investigator on all sponsored projects/research must sign this certification before the proposal can be processed by the Office of Research Administration.
The University of Alabama in Huntsville
Request for Permission to Engage in Consulting Activities
Name: FORMTEXT Rank FORMTEXT Department or Unit: FORMTEXT
College or School: FORMTEXT
Proposed Employer: FORMTEXT
Period of Agreement:Beginning Date: FORMTEXT Ending Date: FORMTEXT (Maximum duration for approval is one year.)
Approximate Time Involved per Month: FORMTEXT
Normal maximum of 36 hours per month.
Nature of Work/Problem (if class, indicate class title and schedule):
FORMTEXT
Please answer the following questions. Attach details to explain each yes response.
1. Will this consulting activity alter or interfere with meeting your obligations to students, faculty,
colleagues or UAH? FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No.
2. Will you involve students or university facilities in any capacity in work performed under the
proposed agreement? FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No.
3. Do you or any members of your immediate family participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the proposed employer or a subcontractor or vendor or of any organization providing goods and/or services for
the proposed project? FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No.
4. Do you or any member of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or controlling interest of the proposed employer or a subcontractor or vendor or any organization providing goods and/or services for this proposed
project? FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No.
CERTIFICATION: This request is made pursuant to the Consulting and Conflict of Interest Policies detailed in the Faculty Handbook. I certify that I have read and understand the policies and will abide by them. I understand that it is my responsibility to insure that my services avoid any conflict of interest and that the permission granted is subject to termination for reasonable cause.
__________________________________ _______________________
Signature of Applicant Date
FORMCHECKBOX Approved _________________________________ ______________________
FORMCHECKBOX DisapprovedChairDate
FORMCHECKBOX Approved _________________________________ ______________________
FORMCHECKBOX DisapprovedDeanDate
Distribution: Provost and Vice President for Academic Affairs; Dean; Chair; Applicant
草榴社区
Disclosure of Extramural Activities
In accordance with the provisions of the Conflict of Interest Policy, this form is to be submitted to the chair and dean to disclose each non-consulting extramural activity for which tangible benefits are received. Examples of instances where pre-disclosure is required include off-campus summer employment, negotiation of a contract to write a textbook or provide instructional software, and acceptance or an appointment to the Board of Directors of a college or corporation. Disclosure using this form is not required for a sabbatical activity already disclosed in the approved request.
Name: FORMTEXT
Title/Rank: FORMTEXT Date: FORMTEXT
College or School: FORMTEXT
External Organization: FORMTEXT
Briefly state the nature of involvement with the external organization:
FORMTEXT
If the extramural involvement has a limited time period (e.g. summer job, etc.), give the time
period:Beginning Date: FORMTEXT
Ending Date: FORMTEXT
Please answer the following questions. If yes is answered to any of the following questions, please describe the nature and extent of the affiliation and attach to this document.*
1. Do you or will you have any affiliation with or commitment to the external organization that would or could interfere with meeting your obligations to students, faculty colleagues or UAH?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
2. Have you or will you involve 草榴社区s in any capacity in work performed for the external organization?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
3. In your relationships with the external organization, are you or will you be associated as thesis or dissertation advisor with any UAH graduate student who is employed with the external organization?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
4. Do you or any members of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the external organization?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
Answer the following questions if you are involved as a principal investigator of any active government sponsored project at UAH.
5. Will the extramural activities affect your ability to complete in a timely manner the objectives of your sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
6. To your knowledge, does the external organization now have or intend to have any business relationship with the funding agency of your UAH sponsored project?
FORMCHECKBOX Yes (Attach details) FORMCHECKBOX No
*Any answer of 揧es� on the questions posed will elicit review by the appropriate dean and if indicated be forwarded with dean抯 comments/recommendations to the Professional Review Committee.
Statement of Policy
This request is made pursuant to the Conflict of Interest Policies detailed in the Faculty Handbook. I understand that it is my responsibility to insure that my extramural activities avoid any conflict of interest. Should a potential conflict arise during the course of such activities, I acknowledge that it is my responsibility to disclose such and seek a resolution.
_____________________________ ________________________________
Signature of Applicant Date
_______________________ ___________________
Chair Date
_______________________ ___________________
Dean Date
Distribution: Provost and Vice President for Academic Affairs; Dean; Chair; Applicant
An Affirmative Action/Equal Opportunity Institution
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