Consultant Commitment Form
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2Office of Research & Engagement, Office of Sponsored Programs, 1534 White Avenue, Knoxville, TN 37996-1529
Phone: 865-974-3466, Fax: 865-974-2805,
osp@utk.edu
Consultant Commitment Form
(1) Project Information
(to be completed by UT)
Proposal Number: __________________________________________________________________________________
(a) UT PI: _______________________________________________ (b) Start & End Dates: ________________________
(c) Prime Sponsor: __________________________________________ (d) Proposed Total Project Costs ____________
(e) Proposal Title: ___________________________________________________________________________________
(2) Consultant Information
(to be completed if consultant is working independently)
(a) Name of Consultant: ______________________________________________________________________________
(b) Address of Consultant: ____________________________________________________________________________
(c) Phone Number: _________________________ (d) Email Address__________________________________________
(3) Consultant Company Information
(to be completed if consultant is working through a consultant company)
(a) Name of Consultant Company: ______________________________________________________________________
(b) Address of Consultant Company: ____________________________________________________________________
(c) Phone Number: ____________________________________ (d) DUNS No.: _________________________________
(4) Financial Conflict of Interest Policy (FCOI) Statement (select one)
(a) Conflict of Interest
(1) Not applicable because this project is not being funded by PHS or any other sponsor that has adopted federal
financial disclosure requirements.
(2) Consultant hereby certifies that its employer has an active and enforced conflict of interest policy that is
consistent with the provision of 42 CFR Part 50, Subpart F “Responsibility of Applicants for Promoting Objectivity
in Research.” Consultant organization also certifies that, to the best of its knowledge, (1) all financial disclosures
have been made related to the activities proposed, and required by its conflict of interest policy; and (2) all
identified conflicts of interest have or will have been satisfactorily managed, reduced or eliminated in
accordance with employer’s conflict of interest policy.
SR001-Oct. 2014
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Parent category: Letters