Conflict of Interest Disclosure

Conflict of Interest Disclosure

Annual COI Disclosure

Please complete this form if you are an investigator and expect to work on ANY research in the coming academic year that is:

-Sponsored NMT research

-Non-sponsored NMT research that is:

Human subject research
Animal subject research
Research funded by a formal award from internal NMT sources based on submission of a proposal.

The COI disclosure is a confidential disclosure. Only the COI Administrator and COI Committee will have access to your information.

The annual COI disclosure will focus on how an investigator’s disclosed outside interests relate to their institutional responsibilities rather than a specific project. Institutional responsibilities are defined as:

“An investigator’s professional responsibilities on behalf of the Institution, including, but not limited to, activities such as research, research consultation, teaching, professional practice, institutional committee memberships, and service on panels such as Institutional Review Boards (IRB) ”

When conflicts are identified the COI Committee creates a management plan in order to mitigate the conflict. All investigators must submit a disclosure annually and if there is a material change to the original disclosure.

I understand and agree with the statement above.*

Investigator Information

Date:*

Full Name*

Primary Work Phone Number:*

Phone

NMT or Primary Work Email:*

Job Title:*

Primary Department/Center/Institute:*

Examples of NMT Affiliated Department/Center/Institute

A professor in Computer Science department who has a joint appointment or works on contracts for ICASA.
Full time staff at EMRTC, with an adjunct appointment in Chemistry.
Full time staff member pursuing a graduate degree in the Earth and Environmental Sciences Department

Affiliated NMT Department/Center/Institute:

Required Disclosure Information

Institutional Committee Member*

Please name committee (e.g. IRB, IACUC, etc.)

Institutional Responsibilities: Other*

Please explain other responsibilities

2. Research/Project Category*

Please check all that apply:

Sponsored NMT research (externally funded)

Non-sponsored NMT research

Internally (NMT) funded research

2.1 Funding Agency Type*

Please check all that apply (If you are unsure, check with your PI):

Public Health Service (PHS) research grant funding (including National Institutes of Health (NIH).

Department of Energy (DOE).

National Science Foundation (NSF).

Department of Agriculture (USDA).

Department of Defense (DoD, Army, Navy, Airforce, Space Force, AFRL, etc.).

Other U.S. Government (federal).

Local or state government.

Private

Private Funding Agency:*

Did the prime award originate from federal funding? (If you are unsure, check with your PI)

Yes

Prime Federal Award Agency:*

Please check all that apply

Public Health Service (PHS) research grant funding (including National Institutes of Health (NIH).

Department of Energy (DOE).

National Science Foundation (NSF).

Department of Agriculture (USDA).

Department of Defense (DoD, Army, Navy, Air Force, Space Force, AFRL, etc.).

Other U.S. Government (federal).

Significant Financial Interest in an External Entity

An Investigator's (includes all researchers) institutional responsibilities are defined as an investigator's professional responsibilities on behalf of the institution, which may include for example: activities such as research, research consultation, teaching, professional practice, institutional committee membership, and service panels.

Please provide as much information as you can describing any interest that you disclose. This will help the COI Committee to better ascertain how your disclosed interest relates to your institutional responsibilities and if there is a potential conflict of interest.

3. NMT Disclosure Questions:*

Do you, your spouse, domestic partner, and/or dependent children have any of the financial interests described below that are related to your institutional responsibilities?

Please select all that apply

Aggregated salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that are expected to total more than $10,000. over the next 12 months.

Intellectual property income and rights, such as patents and copyrights, or royalties from these rights other than through the New Mexico Tech University Research Park Corporation, (NMTRPC).

Equity interests in a single entity, such as stocks, stock options and other ownership interests that are > $10,000.

Equity interests in a single entity, such as stocks, stock options and other ownership interests that represent more than a 5% ownership interest.

None of the above financial interests apply to me, my spouse, domestic partner or dependent children.

PHS or NIH funding:*

Do you, your spouse, domestic partner, and/or dependent children have any of the financial interests described below that are related to your institutional responsibilities?

Please select all that apply

Aggregated salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that are expected to total more than $5,000. over the next 12 months.

Equity interests in a single entity, such as stocks, stock options and other ownership interests that are more than $5,000.

Equity interests in a single entity, such as stocks, stock options and other ownership interests that represent more than a 5% ownership interest.

Intellectual property rights, such as patents and copyrights, or royalties from these rights, other than through NMT.

None of the above financial interests apply to me, my spouse, domestic partner or dependent children.

DOE funding:*

Do you, your spouse, domestic partner, and/or dependent children have any of the financial interests described below that are related to your institutional responsibilities?

Please select all that apply

Aggregated salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that are expected to total more than $10,000 in the previous 12 months.

Director, Officer, Employee, Partner, Trustee, Consultant or Management position in a company doing business related to your research

Intellectual property rights including patents, copyrights, and royalties from such rights except those through NMT.

None of the above financial interests apply to me, my spouse, domestic partner or dependent children.

NSF funding:*

Do you, your spouse, domestic partner, and/or dependent children have any of the financial interests described below that are related to your institutional responsibilities?

Please select all that apply

Aggregated salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that are expected to total more than $10,000. in the 12 months preceding the disclosure.

Intellectual property rights, such as patents and copyrights, or royalties from these rights, other than through NMT.

Any foreign financial interests >$10,000. or >5%.

None of the above financial interests apply to me, my spouse, domestic partner or dependent children.

USDA Funding:*

Do you, your spouse, domestic partner, and/or dependent children have any of the financial interests described below that are related to your institutional responsibilities?

Please select all that apply

Aggregated salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that are expected to total more than $10,000 in the 12 months preceding this disclosure.

Intellectual property rights including patents, copyrights, and royalties from such rights except those through NMT.

Foreign financial interests >$10,000.

None of the above financial interests apply to me, my spouse, domestic partner or dependent children.

Name(s) of the External Entity/Entities:*

What is/are the name(s) of the external entity/entities in which you and/or your family member(s) have a significant financial interest?

External Entity Type(s)?:*

Please check all that apply

Primary Business of the Entity/Entities?:*

Please describe

Positions Held?*

What position do you and/or your family member(s) hold with the entity/entities (e.g., shareholder, director, officer, employee, board member)?

Nature of the Work Performed?*

What is the nature of the work that you and/or your family member(s) perform for this entity/entities?

Written Employment Agreement?*

Do you and/or your family member(s) have a written employment agreement with this entity/entities?

Yes

Research Focus?*

How is the work you and/or your family member(s) perform for this entity/entities similar to or different from the focus of your university research and institutional responsibilities?

Any NMT Resources Used by Entity/Entities?*

Are any NMT resources (e.g. facilities, equipment, employees) used on behalf of the entity/entities?

Yes, in the last 12 months

Yes, within the next 12 months

Amount or Equity Percentage Owned?*

What is/are the general dollar amount or equity percentage that you own of this/these company/companies?

Intellectual property rights?

If applicable, please describe how your Intellectual property rights, such as patents and copyrights, or royalties from these rights are related to your institutional responsibilities.

Conflicting Institutional Responsibilities

An investigator's institutional responsibilities are defined as an investigator’s professional responsibilities on behalf of the institution, which may include for example: activities such as research, research consultation, teaching, professional practice, institutional committee membership, and service panels.

4. Outside Employment, Agreements, Memberships?*

Select all that apply

An agreement with one or more private parties that could appear to give them preferential treatment over a government funding agency or other sponsor of the project (e.g. first delivery of project data).

An agreement to receive financial benefits from the research beyond what is described in the proposal budget submitted to NMT.

Outside employment that could appear to cause a potential conflict with this research, or raise questions about your professional commitments in undertaking the research or your primary allegiance to NMT.

A position as a director, officer, partner, trustee, manager or employee of an outside entity that conducts business in an area related to the research.

I do not have any of the above employment, positions or agreements

4.1 Agreement with Private Party/ies*

Please describe the agreement with one or more private parties that could appear to give them preferential treatment over a government funding agency or other sponsor of the project.

4.2 Agreement to Receive Financial Benefits?*

Please describe the agreement to receive financial benefits from the research beyond what is described in the proposal budget submitted to NMT.

4.3 Outside employment potential conflict*

Please describe your outside employment that could appear to cause a potential conflict with this research.

4.4 Entity Conducting Business in Related Area?*

Please describe your position as a director, officer, partner, trustee, manager or employee of an outside entity that conducts business in an area related to the research that you conduct on behalf of the University.

5. Outside Activities*

Select YES if any of the following statements apply to you:

I hold a direct or indirect interest in an outside entity that conducts business in an area closely related to the NMT research, or serve as a director, officer, partner, trustee, manager or employee in such an entity.
It could reasonably appear that an activity I participate in steers NMT research to serve the research or other needs of an outside entity, without approval of NMT or the research sponsor.
It could reasonably appear that an activity I participate in directs potential research efforts away from NMT and toward an outside entity in which I have a financial interest.
It could reasonably appear that an activity I participate in uses sponsored work products, results, materials, records or information that are not generally made available for personal gain, or transmits such work products, results, materials, records or information to an outside entity without the sponsor's consent.
It could reasonably appear that an activity I participate in uses privileged information acquired in connection with my sponsored NMT research activities for personal gain or for unauthorized purposes (privileged information includes medical, personnel or security records of individuals, anticipated material requirements or price actions, possible new sites for government operations, and knowledge of forthcoming programs or selection of contractors or subcontractors in advance of official announcements).
An outside activity I participate in may put me in a position to negotiate or influence the negotiation of contracts related to my sponsored NMT research between NMT and outside entities with which I have consulting, equity or fiduciary relationships.
I have accepted gratuities or special favors from entities with which NMT does or may conduct business in connection with sponsored NMT research or have extended gratuities or special favors to employees of the sponsor, under circumstances that reasonably might be interpreted as an attempt to influence the recipients in the conduct of their duties.
I have other outside activities associated with my participation in NMT research, where it reasonably appears, on an actual or potential basis, the situation could directly and significantly compromise my professional commitments or allegiance to NMT.

Yes

5.1 Please Explain Outside Activities*

Include the number of the statement(s) that apply and a description of the activities

6. Research Collaboration with Family*

With respect to your NMT research, do you collaborate with any family members?

Yes

Please describe collaboration *

Please describe the nature of the collaboration, the name(s) of family member(s) and their relationship to you

7. Do you use human subjects in your research?*

Yes

Human Based Subject Research

Federal regulations require that any and all proposed research involving human subjects be reviewed and approved by an Institutional Review Board (IRB) for the Protection of Human Subjects in Research PRIOR to initiation of such research.

This requirement applies to all human subject research conducted by faculty, staff, or students, on or off campus, regardless of the source of funding for the project.

All research at New Mexico Tech that involves human subjects must be submitted to the IRB for review before such research can be performed.

Applications & Information for IRB project approval/extension can be found at www.nmt.edu/research/irb.php

Do you have an IRB Project Application?*

Yes

Have you received IRB approval?*

Yes

It is pending approval

8. Malign Foreign Talent Recruitment Programs*

Certification Regarding Malign Foreign Talent Recruitment Programs

In accordance with Section 10632 of the CHIPS and Science Act of 2022 (42 U.S.C. § 19232), the AOR must certify that all individuals identified as senior/key personnel have been made aware of and have complied with their responsibility under that section to certify that the individual is not a party to a malign foreign talent recruitment program.

For the definition of the Malign Foreign Talent Recruitment Programs please visit: www.nmt.edu/research/iecp.php and consult the CHIPS and Science Act of 2022.

Are you a party to or do you participate in any Malign Foreign Government Sponsored Talent Recruitment Program?

Yes

COI Agreement

COI Agreement*

By checking the box below, I agree to abide by New Mexico Tech's Conflicts of Interest in Research policy and associated procedures. In submitting this disclosure, I certify that the information provided is true to the best of my knowledge. I supply this information for confidential review by New Mexico Tech, and for such other limited purposes as are required by law, regulation, or contract. I do not authorize release of any of it for any other purpose.

Material Change Recertification*

I understand and agree that by checking the box below, I must submit a new disclosure within 30 days of any material change (an acquisition of a significant financial interest) to the information submitted on this form.

Comments or Suggestions

In the space below, please provide any comments or suggestions that you have on the format and functionality of the Annual FCOI Disclosure Process so that we can make continual improvements to this process.

Send me a copy of my responses

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