Certification Of Financial Disclosure
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2Certification of Financial Disclosure and Training for PHS Investigators
Investigator Last Name
Department
Investigator First Name
College
UIeRA # (ex. 2012-01111)
UIUC Grant Code (ex. A0123)
Project Title:
Phone Number
Email
Please list all Investigators participating in the above-referenced proposal/award. These individuals
must complete PHS Investigator Training, and a PHS Investigator Financial Interest Disclosure.
Verification of completion of training and the disclosure form should be submitted to Melanie Loots at
the OVCR, or via email to phsdisclosure@illinois.edu. For each individual you should also then complete
Columns 1 and 2 of this Certification. When the information for each Investigator is complete, please
sign and submit this form to the OVCR for review. If you have any questions, please call Melanie Loots at
(217) 333-0034.
1. Insert the names of all Investigators. Investigators, as defined under the HHS regulations, include
PIs, co-PIs, postdocs, research scientists, graduate research assistants, and potentially others who
play a key role, such as emeritus faculty members or research fellows paid on other sources of
funds.
2. Verify with all Investigators that they have completed ONE of the training options available at
and indicate completion of the training on
this form.
3. EVERY INVESTIGATOR MUST COMPLETE A FINANCIAL INTEREST DISCLOSURE FORM even if there is
nothing to report. Please indicate completion of disclosure for each investigator.
4. Please verify with all Investigators that they are up to date on disclosures of reimbursed or
sponsored travel.
5. The OVCR will indicate whether a financial conflict of interest has been identified, consulting with
the home unit or institute as needed.
6. The OVCR will indicate whether a conflict management plan for the activity is in place.
7. This form must be signed by the Principal Investigator of the proposal submission.
8. When completed, RETURN THIS FORM TO THE OVCR. The OVCR will review and confirm conflict
management, if it is needed, and forward a copy of the Certification to OSPRA indicating the review
is complete. OSPRA will then make the award available for account setup. No activity is allowed on
the project until the OVCR review is complete.
9. The PHS Investigator Financial Interest Disclosure form, detailed instructions, and additional
information related to the HHS regulations, and UIUC's implementation of those regulations are
online at
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