Conflict of Interest Disclosure

 

Conflicts of Interest in Research 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 or designee will have access to your information.


The disclosure questions 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 include but are not limited to: research, research consultation, teaching, professional practice, institutional committee memberships, and service on panels such as Institutional Review Boards (IRB).


When conflicts are identified and can be managed, the COI Committee creates a management plan in order to mitigate the conflict. All investigators must submit a disclosure annually, and within 30 days of a material change to the original disclosure.

 
 

Investigator Information

 
 
mm/dd/yyyy
 
 
Phone
 
 
 
 

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
 
 
 

Required Disclosure Information

 

Please check all that apply:

 

Please check all that apply:

 

Significant Financial Interest in an External Entity

An Investigator's institutional responsibilities are defined as the investigator's professional responsibilities on behalf of the institution, which include but are not limited to: 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.

 

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

 

 

Conflicting Institutional Responsibilities

An investigator's institutional responsibilities are defined as the investigator’s professional responsibilities on behalf of the institution, which include but are not limited to: research, research consultation, teaching, professional practice, institutional committee membership, and service panels.


 

Select all that apply to you, as they relate to your NMT institutional responsibilities

 

Activities Outside The University

 

Select all of the following statements that apply, or could reasonably appear to apply to you:

 

 

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

 
 

Animal Subjects Research

All Vertebrate Animal Research must be reviewed and approved by the NMT IACUC.


NMT's Office of Research Compliance and Safety provides consultation and compliance services to researchers considering conducting Animal Research.


Any questions or concerns regarding the NMT Animal Care and Use Program should be directed to iacuc@nmt.edu

 

Vertebrate or Invertebrate animals

 

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.

 

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.


 

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.


 
 

Powered by
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.