Conflict of Interest 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:
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.
Please check all that apply:
Please name committee (e.g. IRB, IACUC, etc.)
Please explain other responsibilities
Please check all that apply (If you are unsure, check with your PI):
Did the prime award originate from federal funding? (If you are unsure, check with your PI)
Please check all that apply
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
Describe the salary, royalties or other payments, such as consulting fees and honoraria, other than through NMT, that when aggregated total more than $5,000 over the previous 12 months.
Describe the 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).
Describe the equity interests in a single entity, such as stocks, stock options and other ownership interests that are > $5,000. Include the dollar value of the interest.
Describe any travel, over the previous twelve (12) months, related to your work, that was paid for or reimbursed by any entity other than NMT or your funding agency.
Describe the equity interests in a single entity, such as stocks, stock options and other ownership interests that represent more than a 5% ownership interest.
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?
Please describe
What position do you and/or your family member(s) hold with the entity/entities (e.g., shareholder, director, officer, employee, board member)?
What is the nature of the work that you and/or your family member(s) perform for this entity/entities?
Do you and/or your family member(s) have a written employment agreement with this entity/entities?
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?
Check all of the following relationships that the entity/entities has with NMT.
Are any NMT resources (e.g. facilities, equipment, employees) used on behalf of the entity/entities?
What is/are the general dollar amount or equity percentage that you own of this/these company/companies?
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.
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
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.
Please describe the agreement to receive financial benefits from the research beyond what is described in the proposal budget submitted to NMT.
Please describe your outside employment that could appear to cause a potential conflict with this research.
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.
Select all of the following statements that apply, or could reasonably appear to apply to you:
Describe the 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.
Describe how the activity you participate in steers NMT research to serve the research or other needs of an outside entity, without approval of NMT or the research sponsor.
Describe how the activity you participate in directs potential research efforts away from NMT and toward an outside entity in which I have a financial interest.
Describe how the activity you 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.
Describe how the activity you 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
Describe how the outside activity you 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 you have consulting, equity or fiduciary relationships.
Describe when you 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.
Describe in what way 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.
With respect to your NMT research, do you collaborate with any family members?
Please describe the nature of the collaboration, the name(s) of family member(s) and their relationship to you
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
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
I understand at this time NMT does not hold current federal assurances or approved campus facilities to support vertebrate animal research on campus.
Please contact iacuc@nmt.edu for assistance with protocol review and approval for field research or research on vertebrate animals housed at an approved facility.
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?
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.