Conflict of Interest Disclosure Form

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1 Fill out this paper form only if you are not required to complete the University s on-line outside interest disclosure form (M-Inform) and have a real, perceived or potential conflict of interest. Please check with your supervisor or contact dds-compliance@umich.edu if you do not know if you are required to complete this form. Please return completed forms to your supervisor or committee chair, as appropriate, or contact ddscompliance@umich.edu for routing assistance. See definitional section for italicized words. General Information Name (Last, First, Middle): Date: Job Title: UM Employee Yes No Department/Unit: Phone # Supervisor's Name: Part I: Preliminary Questions Yes No a. I participate or expect to participate as an investigator in Public Health Service funded research within 90 days (NIH, AHRQ, SAMHSA, HRSA, FDA, CDC, ATSDR, HIS, etc.). Stop: If you answered yes to Part I(a), you must complete the on-line disclosure form. To do this, go to If you cannot logon, please contact dds-compliance@umich.edu for assistance. If you answered no, please continue filling out this form. b. I or my spouse, domestic partner, or dependents: Yes No Attend a UM School of Dentistry Committee that requires an outside interest, activity or relationship disclosure (go to for assistance) Engage in paid or unpaid outside activities, interests, or relationships that are related to my UM institutional responsibilities Hold ownership in a company or business (including equity, stock, or stock options) that is related to my UM institutional responsibilities. Hold ownership in a company or business (including equity, stock, or stock options) that seeks to do business with the University or its employees. Receive or expect to receive compensation, loans (other than student loans), other payment(s) or items of value related to my UM institutional responsibilities. Make purchasing decisions for or at the University related to my institutional responsibilities. Participate as an investigator on non-phs funded research sponsored by an outside organization related to my UM responsibilities and with which I, my spouse, domestic partner, or dependents have a paid or unpaid interest, activity, or relationship. Stop: If you answered no to all questions in Part I(a) and (b), please review your answers with your supervisor or committee leadership, as appropriate, and go to Part III, Section A to sign and date this form. A copy of this form should be kept on file by you, your supervisor or committee leadership. Please forward an electronic copy to your human resources representative and to dds-compliance@umich.edu. If you answered yes to any of the questions in Part I (b), please continue filling out this form. Version

2 Part II. Complete this form separately for each outside organization related to your institutional responsibilities and with which you, your spouse, domestic partner, or dependents have an interest, activity, or relationship. Part II: Outside Interest, Activity, or Relationship Detail Information Section A: Outside Organization Information Activity, Interest, or Relationship is for (select all that apply): Me Spouse, Domestic Partner, or Dependent Name of Outside Organization involved in this interest, activity, or relationship Duration of Interest, Activity or Relationship: Ongoing Publicly Traded Non-Publicly Traded Other (non-profit, etc.) Date Specific - add actual or estimated dates: Or Start Date: End Date: Section B: Interest, Activity, or Relationship with Outside Organization 1. Select the following descriptors that apply to the outside organization identified in Part II, Section A: Consultant/Advisor Expert Witness Speakers Bureau Conduct Training Employee Advisory, Strategic, or Medical Board Lecturer Honoraria Other (Please describe): Leadership role Officer (trustee, manager, president) Leadership role Director (member; not an officer) 2. Select all that apply to your financial arrangement with this outside organization: Equity Interest (stock, stock option, other ownership or partnership interest). Percent (%) Ownership: < 1% 1% - 5% >5% Receive payments related to intellectual property (e.g., royalties, milestone, option fees, etc.) Distributed by UM Distributed by the outside organization involved in this interest, activity, or relationship Both Other (e.g., agreements or other contractual relationships). Please describe: 3. Remuneration expected from the outside organization identified in Part II, Section A, for fiscal year July 1 to June 30. Fiscal Year (July 1 to June 30) Version

3 Part III: Signatures and Conflict Management Strategies (where applicable) to reduce or eliminate any identified conflicts of interest. Part III. Attestation and Conflict Management Strategies (if applicable) Section A: Attestation (Signature and Date Required Fields) I certify that the information provided is accurate to the best of my knowledge. I agree that I will update this disclosure promptly when my circumstances change. I understand that failure to fully and honestly disclose my outside interests, activities, or relationships can result in disciplinary action up to and including termination. I certify that I have read and agree to abide with UM School of Dentistry Policy (Faculty) or Policy (staff) related to Outside Interests and Conflicts of Interest and SPG , Conflicts of Interest and Conflicts of Commitment. Print Name (Disclosing Party) Signature Date I certify that I reviewed the completed outside interest disclosure form and agree that a conflict management plan is not applicable for the disclosing party. Print Name (Manager or Committee Chair) Signature Date Section B: Conflict Management Strategies to Reduce or Eliminate Identified COI Describe Conflict(s) of Interest: Outline COI Management Strategies (working with your supervisor, describe the steps that you will take to reduce or eliminate the identified conflict of interest (use an additional sheet of paper if necessary.) I will abide by the conflict management strategies outlined above. I agree to promptly update these management strategies when my circumstances change. I understand that failure to comply with the outlined management strategies can result in disciplinary action up to and including termination. Print Name (Disclosing Party) Signature Date I certify that I reviewed the completed outside interest disclosure form and agree that a conflict management plan is not applicable for the disclosing party. Print Name (Manager or Committee Chair) Signature Date Version

4 DEFINITIONS Conflict of Interest Disclosure Form Public Health Service Agencies within the Public Health Service include: Agency for Toxic Substances and Disease Registry (ATSDR); Centers for Disease Control and Prevention (CDC); Food and Drug Administration (FDA); Health Resources and Services Administration (HRSA); Indian Health Services (IHS); National Institutes of Health (NIH); Substance Abuse and Mental Health Services Administration (SAMHSA). Outside Organization is any commercial, for profit (publicly traded or not) company, and any non-profit, or non-governmental, entity other than the University of Michigan. Outside interest, activity, or relationship is a non-university interest, activity, or relationship, whether paid or unpaid. Related is when an outside interest, activity, or relationship relies upon the same expertise that an individual s ability to carry out his or her institutional responsibilities relies upon. Also, any interest, activity, or relationship that has the potential to influence the duties that the University considers part of the work it pays or otherwise engages an individual to do. Institutional Responsibilities refers to an individual s professional responsibilities on behalf of the University, such as research, teaching, conduct of sponsored projects, professional practice, and service on institutional committees. Remuneration means payments of any kind from an outside organization, except: payments from a federal, state, or local government agency, a domestic nonprofit institution of higher education; income from investment vehicles such as mutual funds and retirement accounts; book royalties and royalties paid through UM. Conflict of Interest or COI exists whenever personal, professional, commercial, or financial interests or activities outside of the University or UM School of Dentistry have the possibility (either in actuality or in appearance) of: Compromising a UM School of Dentistry faculty or staff s judgment, Biasing the nature or direction of scholarly research, Influencing a UM School of Dentistry faculty, house officer or staff s decision or behavior with respect to teaching and student affairs, appointments and promotions, uses of University or UM School of Dentistry resources, interactions with patients or human subjects, or other matters of interest to the University or UM School of Dentistry, or Resulting in a personal gain for a UM School of Dentistry faculty, or staff or for their Family Members' gain or advancement at the expense of the University or UM School of Dentistry. DISCLOSURE PRIVACY STATEMENT The information you provide in this document is collected in accordance with the requirements of the UM School of Dentistry Policy (Faculty) or Policy (staff) related to Outside Interests and Conflicts of Interest. These policies require the disclosure of all potential material conflicts of interest by an individual to their supervisor. Failure to disclose potential conflicts could lead to disciplinary action up to and including termination. Sensitive and Confidential Information UM School of Dentistry recognizes that the information provided by you in this disclosure is personal and sensitive. UM School of Dentistry considers the information to have been given in confidence, and undertakes to treat it confidentially to the extent permitted by law. The information you provide related to your conflict may be disclosed to others that need this information to perform their UM School of Dentistry obligations or to make decisions on behalf of UM School of Dentistry (e.g., Human Resources, Compliance Officer, Conflict of Interest boards or committees, Health System Legal Office, etc). The information you provide is available through the Michigan Freedom of Information Act, Public Act No. 442 of Access and Retention Version

5 This document and any copies will be retained in your personnel file. It will be accessible only to those that demonstrate a need to view this information. Version

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