Fillable Consultant Commitment Form (Page 2 of 2) in pdf

Consultant Commitment Form Page 2

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Certification by Authorized Organizational Official (to be completed if option 2 is checked)

I certify the information listed above is true, complete and accurate to the best of my knowledge, and that I

am an Authorized Organizational Official for my institution/organization. My organization is aware of the

2011 revised PHS FCOI regulations, and we are prepared to enter into an inter-institutional agreement (if

applicable) that requires adherence with the provisions of 42 CFR Part 50, Subpart F “Responsibility of

Applicants Promoting Objectivity in Research.”

Signature: ___________________________________________ Date: _________________________________

Printed Name: ________________________________________ Title: _________________________________

Name of Institution: __________________________________________________________________________

(3) Consultant does not have an active and/or enforced conflict of interest policy and hereby agrees to abide by

UT’s policy. UT’s policy is available at

(5) Documentation (900 character limit. If more space is needed, please attach additional pages.)

(a) Description of Services to be provided:

(b) Rate of Compensation (include number of days or hours of expected service)

(6) Approvals of Consultant

(to be completed by Consultant if Section 2 is completed above)

Signature: ___________________________________________________________ Date: _________________________

(7) Consultant Information

(to be completed by Consultant Company if Section 3 is completed above)

Consultant Company Representative

Signature: ___________________________________________________________ Date: _________________________

Name and Title: __________________________________________________ Phone: ____________________________

Address: ___________________________________________________________________________________________

City, State, Zip: _______________________________________________ email: ________________________________

Note: Any work begun or expenses incurred prior to execution of an agreement is at the Contractor’s own risk.

SR001-Oct. 2014

Page 2 of 2

Consultant Commitment Form Page 2

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