ATTACHMENT B
PART II
FINANCIAL DISCLOSURE STATEMENT
EXPLANATION FORM
NAME_____________________________________________________________
DEPARTMENT______________________________________________________
Name of the organization/agency with which an actual, perceived, or potential conflict
of interest may exist:
__________________________________________________________________
Whose affiliation with this organization/agency creates the actual or potential
conflict of interest?
__________________________________________________________________
What is the nature and extent of this affiliation? (e.g., consulting fees of $20,000
per year paid to the faculty/staff member; the faculty/staff member, spouse, and children
own an aggregate of 40% of the stock in the agency funding this sponsored project;
royalties to the faculty/staff member and their Family/Household pay an annual income of
approximately $15,000)
__________________________________________________________________
Signature______________________________________ Date ______________
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