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CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CONFLICT OF INTEREST DISCLOSURE FORM
Investigator Name:
Department/College:
Project Title:
Proposed Sponsor:
AT THIS TIME, I HAVE NOTHING TO DISCLOSE
I am disclosing my following significant financial interests in the prime funding entity (the entity from which project funds originate), a
pass-through entity (an entity distributing project funds from the prime funding entity to CSUN), or a subrecipient of funds (an entity
receiving project funds from CSUN). (Responses should include significant financial interests held by the investigator, his/her spouse, and
any dependent children.)
Name of Entity:
Address of Entity:
Principal Type of Business:
If Entity is the Sponsor, Amount of Funding Request: $
Are you a director, officer, partner, trustee, or employee of the entity?
Yes
No
Do you have an investment of $1,000 or more in the entity?
Yes
No
Do you hold an equity position of 5% in the entity?
Yes
No
Have you received income of $250 or more or gifts valued at $50 or
more from the entity? (Exclude income received from the entity for
a current or previously funded project administered through CSUN.)
Yes
No
Have you received a loan from the entity for which the outstanding
balance exceeded $250 in the past 12 months?
Yes
No
Do you have an interest in any intellectual property rights
Yes
No
belonging to the entity?
Investigator Certification:
• I agree to update this disclosure as new reportable significant financial interests are obtained.
• I agree to cooperate in the development of a Resolution Plan to address any actual or potential conflict of interest identified in this Disclosure.
• I agree to comply with any conditions or restrictions imposed by CSUN to manage, reduce, or eliminate actual or potential conflicts of
interest or forfeit the award.
Signed:
Date:
Investigator
FOR CSUN OFFICE OF RESEARCH AND SPONSORED PROJECTS USE ONLY
No further review required. The investigator disclosed no significant financial interests. Date: __________ Staff Initials: _________
Referred to Associate Vice President, Research and Graduate Studies or designee (AVP). Date: _________ Staff Initials: ________
AVP determined no conflict of interest exists. Date: __________ AVP Initials: _________
AVP determined a conflict of interest exists and will develop a Resolution Plan. Date: __________ AVP Initials:_________
Revised 6/15