ࡱ> ~}7 ]4bjbjUU "z7|7|S(l8888888Lzzzz\Ls8<v4444"1111-14|7$9 ;78###7%8844-8%%%# 84841%#1%p%-88-4j P;Y]L.z)#--C80s8-e<#e<-%LL8888APPENDIX J Disclosure Forms for Consulting Activities 鶹ƷƵ Principal Investigator Disclosure Of External Affiliations (To be appended to Extramural Funding Proposal Coordination Sheet) Faculty Members Name  FORMTEXT      School/College  FORMTEXT       Title/Rank  FORMTEXT      Date  FORMTEXT       Title of Proposed Sponsored Project  FORMTEXT       Name of Funding Sponsor/Other  FORMTEXT       Proposed Period of Project: Beginning Date  FORMTEXT       Ending Date  FORMTEXT       Please answer all questions. If  yes is answered to any question, please describe the nature and extent of the affiliation and attach to this document.* 1. Will acceptance of this sponsored program interfere with meeting your obligations to students, faculty colleagues or 鶹ƷƵ?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 2. Do you or will you have any affiliation with the proposed external funding organization, a subcontractor or vendor that would or could interfere with meeting your obligations to students, faculty colleagues or 鶹ƷƵ?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 3. Other than as described in the proposal, do you plan to involve students in any capacity in the proposed work for this external funding organization during the course of this sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 4. Do you or any members of your immediate family participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the external funding organization, a subcontractor or vendor or of any organization providing goods and/or services for the sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 5. Do you or any member of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or controlling interest of the external funding organization, a subcontractor or vendor or any organization providing goods and/or services for this sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No Answer questions 6 and 7 if this is a government sponsored project. 6. Have you or any member of your immediate family received significant income from a subcontractor or vendor or organization providing goods and/or services for this proposed sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 7. Do you or any member of your immediate family anticipate receiving significant income from a subcontractor or vendor or any organization providing goods and/or services for this proposed sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No * Any answer of yes on the questions posed will elicit review by the appropriate dean and if indicated be forwarded with deans comments/recommendations to the Professional Review Committee. CERTIFICATION** I hereby certify that I have read and understood 鶹ƷƵ Conflict of Interest policy. Furthermore, should any potential or actual conflict of interest arise during the conduct of the proposed research, I acknowledge that I have an obligation to disclose immediately such conflicts in writing to the chair and dean and seek resolution. Faculty Member Signature Date  FORMCHECKBOX  Approved  FORMCHECKBOX  DisapprovedChair SignatureDate  FORMCHECKBOX  Approved __________________________ _________  FORMCHECKBOX  DisapprovedDean Signature Date** Each principal investigator on all sponsored projects/research must sign this certification before the proposal can be processed by the Office of Research Administration. The University of Alabama in Huntsville Request for Permission to Engage in Consulting Activities Name:  FORMTEXT      Rank  FORMTEXT      Department or Unit:  FORMTEXT       College or School:  FORMTEXT       Proposed Employer:  FORMTEXT       Period of Agreement:Beginning Date: FORMTEXT      Ending Date: FORMTEXT       (Maximum duration for approval is one year.) Approximate Time Involved per Month:  FORMTEXT       Normal maximum of 36 hours per month. Nature of Work/Problem (if class, indicate class title and schedule):  FORMTEXT       Please answer the following questions. Attach details to explain each  yes response. 1. Will this consulting activity alter or interfere with meeting your obligations to students, faculty, colleagues or 鶹ƷƵ? FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No. 2. Will you involve students or university facilities in any capacity in work performed under the proposed agreement? FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No. 3. Do you or any members of your immediate family participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the proposed employer or a subcontractor or vendor or of any organization providing goods and/or services for the proposed project? FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No. 4. Do you or any member of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or controlling interest of the proposed employer or a subcontractor or vendor or any organization providing goods and/or services for this proposed project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No. CERTIFICATION: This request is made pursuant to the Consulting and Conflict of Interest Policies detailed in the Faculty Handbook. I certify that I have read and understand the policies and will abide by them. I understand that it is my responsibility to insure that my services avoid any conflict of interest and that the permission granted is subject to termination for reasonable cause. __________________________________ _______________________ Signature of Applicant Date  FORMCHECKBOX  Approved _________________________________ ______________________  FORMCHECKBOX  DisapprovedChairDate  FORMCHECKBOX  Approved _________________________________ ______________________  FORMCHECKBOX  DisapprovedDeanDate Distribution: Provost and Vice President for Academic Affairs; Dean; Chair; Applicant 鶹ƷƵ Disclosure of Extramural Activities In accordance with the provisions of the Conflict of Interest Policy, this form is to be submitted to the chair and dean to disclose each non-consulting extramural activity for which tangible benefits are received. Examples of instances where pre-disclosure is required include off-campus summer employment, negotiation of a contract to write a textbook or provide instructional software, and acceptance or an appointment to the Board of Directors of a college or corporation. Disclosure using this form is not required for a sabbatical activity already disclosed in the approved request. Name:  FORMTEXT       Title/Rank:  FORMTEXT      Date:  FORMTEXT       College or School:  FORMTEXT       External Organization:  FORMTEXT       Briefly state the nature of involvement with the external organization:  FORMTEXT       If the extramural involvement has a limited time period (e.g. summer job, etc.), give the time period:Beginning Date:  FORMTEXT       Ending Date:  FORMTEXT       Please answer the following questions. If  yes is answered to any of the following questions, please describe the nature and extent of the affiliation and attach to this document.* 1. Do you or will you have any affiliation with or commitment to the external organization that would or could interfere with meeting your obligations to students, faculty colleagues or 鶹ƷƵ?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 2. Have you or will you involve 鶹ƷƵ students in any capacity in work performed for the external organization?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 3. In your relationships with the external organization, are you or will you be associated as thesis or dissertation advisor with any 鶹ƷƵ graduate student who is employed with the external organization?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX No 4. Do you or any members of your immediate family hold more than five percent (5%) actual or beneficial ownership of the voting stock or participate as an officer, partner, director, trustee, employee, advisory/other board member, or agent in any capacity with the external organization?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No Answer the following questions if you are involved as a principal investigator of any active government sponsored project at 鶹ƷƵ. 5. Will the extramural activities affect your ability to complete in a timely manner the objectives of your sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No 6. To your knowledge, does the external organization now have or intend to have any business relationship with the funding agency of your 鶹ƷƵ sponsored project?  FORMCHECKBOX  Yes (Attach details) FORMCHECKBOX  No *Any answer of Yes on the questions posed will elicit review by the appropriate dean and if indicated be forwarded with deans comments/recommendations to the Professional Review Committee. Statement of Policy This request is made pursuant to the Conflict of Interest Policies detailed in the Faculty Handbook. I understand that it is my responsibility to insure that my extramural activities avoid any conflict of interest. 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