CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
CONFLICT OF INTEREST DISCLOSURE FORM
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?
Do you have an investment of $1,000 or more in the entity?
Do you hold an equity position of 5% in the entity?
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.)
Have you received a loan from the entity for which the outstanding
balance exceeded $250 in the past 12 months?
Do you have an interest in any intellectual property rights
belonging to the entity?
• 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.
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:_________