INSTRUCTIONS: CPHS Checklist for Human Subjects Financial Conflict of Interest

• This Checklist must be included with all new and renewal applications, and with amendment applications if appropriate (e.g., if there are changes in study personnel or funding sources).  If the project’s lead investigator has Principal Investigator status, her/his name should be listed at the top as “Principal Investigator” and s/he should sign at the bottom on the line labeled “Principal Investigator Signature.”  However, if the lead investigator has student or other non-PI status only, their Faculty Advisor/Mentor should be listed at the top as “Principal Investigator,” and the Advisor/Mentor should sign at the bottom on the line labeled “Faculty Mentor Signature,” with the student’s name printed beside this as indicated.

• At least one copy of the Checklist should bear the original signature of the Lead/ Principal Investigator or Faculty Advisor (as above). Signatures should be legible. Additional copies of the signed Checklist may be photocopied.

• The CPHS Checklist for Human Subjects Financial Conflict of Interest pertains to the entire project team working under the research protocol. Individuals who are responsible for the design, conduct, analysis, and/or reporting of the results of the study must disclose whether or not they have any financial interest in or association with the sponsor or company supplying the materials, drugs, devices, or support for the project.

• Each individual with a positive (“yes”) response to questions 1, 2, or 3 on the Checklist is required to complete and submit an additional form, the UCB Human Subjects Financial Conflict of Interest Form (see below).

INSTRUCTIONS: UCB Human Subjects Financial Conflict of Interest Form

• This form must be completed and submitted if applicable with the CPHS Checklist for Human Subjects Financial Conflict of Interest (see directly above).

• In such cases, OPHS staff will forward the materials to the UCB Conflict of Interest Committee for separate review; the COI Committee will then communicate directly with the investigator on all matters related to COI review. Final CPHS approval or determination of exemption will be contingent upon the disclosure and resolution of all financial conflicts of interest, as determined by the COI Committee.