ORI FCOI Disclosure Form

The ORI Disclosure Smartsheet form is a new and improved way of disclosing any outside relationships or interests that may reflect a conflict of interest for your research at Drexel University. This form replaces the old paper-based forms (FCOI Disclosure Form 1 & FCOI Disclosure Form 2) and simplifies the process for research.

Investigator/ Personnel Profile

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Example: abc1234

REQUIRED TRAINING: (CITI TRAINING)

All primary investigators, co-investigators, and key personnel engaging in research related to sponsored and unsponsored projects must complete COI training for Drexel University to remain compliant per the University’s policy on Research Conflict of Interest in Research.*

Training details:

  • Drexel University uses the online CITI Training program to meet this requirement CITI Training.
  • Training is required every four years.


Please certify that you have reviewed, understand, and completed the required training.

Type of Disclosure:*
  • Interim - When you add or revise an SFI – (within 30 days of acquiring the new financial interest); or
  • Project-specific - At time of proposal – if you didn’t complete a COI disclosure at the time of award, or
  • Annually – all researchers are required to submit an annual disclosure in a 12-month period.
Foreign Talent Programs*

In the last 12 months have you participated in any foreign talent programs?


Definition: A Foreign Talent Recruitment Program is any program, position, or activity that includes compensation in the form of cash, in-kind compensation, including research funding, promised future compensation, complimentary foreign travel, things of non de minimis value, honorific titles, career advancement opportunities, or other types of remuneration or consideration directly provided by a foreign country at any level (national, provincial, or local) or their designee, or an entity based in, funded by, or affiliated with a foreign country, whether or not directly sponsored by the foreign country, to an individual, whether directly or indirectly stated in the arrangement, contract, or other documentation at issue.

If yes, please list the foreign talent program/programs

Interim Disclosure

Project-Specific Disclosure

Proposal/ Protocol Designation*

Please designate whether the FCOI Disclosure is associated with a COEUSLite Proposal or IRB Protocol.

Proposal # should be a 8 digit number. Example: 00025XXX

IRB Protocol # should be a 10 digit number. Example: 250XXXXXXX

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Do you have any conflicts as it relates to this project?*

What is a conflict

Conflict of Interest Advisory Memo

Annual Disclosure

Outside Relationships:*

Are you involved in the oversight, management, or participation in any sponsored or internally funded research projects at another institution or company, including international institutions, where Drexel is not involved?

Do you have an Intellectual Property / IP?*
Do you have active Comprehensive Management Plan (CMP) ?*
Outside Remuneration :*

In the last 12 months, did you, or an immediate family member receive any remuneration* related to the research or not, that may reasonably appear to be related to your institutional responsibilities?


Remuneration includes salary or any payment for services not otherwise identified as salary, e.g., consulting fees, honoraria, paid authorship fees, that were paid from any entity other than Drexel University. Do not include income that was reimbursed or sponsored by a Federal, state, or local government agency, an institution of higher education as defined by 20 U.S.C. 1001(a), an academic teaching hospital, a medical center, or a research institute that is affiliated with an institution of higher education.

Outside Equity Interest:*

In the last 12 months, did you, or an immediate family member hold an equity interest in a publicly or non-publicly traded entity, related to intellectual property interests (e.g., patents, copyrights), that may reasonably appear to be related to your institutional responsibilities?


Equity interests include any stock, stock options, or other ownership interests. Do not include income from investment vehicles, such as mutual funds and retirement accounts if you, or an immediate family member do not directly control the investment decisions.

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Royalties or Other Income Related To IP :*

In the last 12 months, have you, or an immediate family member, received royalties or other income related to intellectual property interests (e.g., patents, copyrights), whether related to the research or not, that may reasonably appear to be related to your institutional responsibilities?


This does include IP rights assigned to Drexel and agreements to share in royalties related to such rights (e.g., royalties received under the relevant Intellectual Property Policy). Please provide an estimated amount of royalties received or expected to receive in the last 12 months.

Sponsored Travel:*

In the last 12 months have / will you receive(d) sponsored travel reimbursement?

If yes, please explain (Ex: conference name, purpose, destination, collaborators, duration, cost)

1. ENTITY DETAILS

Please provide a description of the entity(business) or service(s) provided.

Business structure of entity*
What is the role of the entity in the project?*
Please provide the cumulative value of financial interest.*

If unascertainable, please explain.

Do you have any other entity to disclose?*

2. ENTITY DETAILS

Please provide a description of the entity(business) or service(s) provided.

Business structure of entity*
What is the role of the entity in the project?*
Please provide the cumulative value of financial interest.*

If unascertainable, please explain.

Do you have any other entity to disclose?*

3. ENTITY DETAILS

Please provide a description of the entity(business) or service(s) provided.

Business structure of entity*
What is the role of the entity in the project?*
Please provide the cumulative value of financial interest.*

If unascertainable, please explain.

Do you have any other entity to disclose?*

If yes, please reach out at fcoi@drexel.edu

CERTIFICATION

I hereby declare that I have read and understood the COI policy and that I will report any activities that may exceed the $5,000 threshold for a single domestic entity in any rolling 12-month period.


I also affirm that I have answered the above questions truthfully and accurately and that no one else has filled out this form for me or on my behalf.


Please sign this document by typing your full legal name below

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