ࡱ> 9;8y -bjbj 8&{{25lll8$4!  {!}!}!}!}!}!}!$#&X!l"!!X8l{!{!OTMoPgg!!0!o,&&&l!!!& : Form B Eastern Illinois University Financial Interest Review Form 1. Investigator Name: ________________________________________________________________________ 2. PHS Project Title: __________________________________________________________________________ 3. Disclosed Financial Interest: _________________________________________________________________ Part 1: Identifying a Significant Financial Interest 4. Does the disclosed financial interest appear to be reasonably related to the investigators institutional responsibilities? ( Yes ( No Briefly explain the reasoning behind the conclusion: If the answer is yes, then the financial interest is a Significant Financial Interest (SFI). Proceed to 5. If the answer is no, then the financial interest is not a Significant Financial Interest. Skip all remaining parts of this form except the signature. Part 2: Identifying a Financial Conflict of Interest (FCOI) 5. Determine relatedness by answering both questions A. and B. A. Could the SFI be affected by the PHS-funded research? ( Yes ( No B. Is the SFI in an entity whose financial interest could be affected by the research? ( Yes ( No 6. Could the SFI directly and significantly affect the design, conduct, or reporting of PHS-funded research? ( Yes ( No If the answer to either question 5. A. or 5. B. is yes AND if the answer to question 6 is yes, then the SFI is a FCOI. 7. Conclusion (check one): ( The SFI is an FCOI ( The SFI is not an FCOI. Part 3: Reporting to the PHS 8. A report to the PHS ( is required. ( is not required. ___________________________________________________________________________________________ Part 4: Verification of Analysis (Parts 1 3) by Institutional Official Signature:___________________________________________ Date:_________________________ Institutional Official ___________________________________________________________________________________________ Part 5: Verification of Reporting to the PHS 9. A report to the PHS was submitted on __________________. Date Signature:___________________________________________ Date:_________________________ Institutional Official     Rev. Aug. 2012 See Reverse Side FCOI File No.: _________ Date received: __________  %/78>CDE  l m n # % & ʾ|rkr|e_S jchQ}hQ}CJ hQ}CJ h CJ h^5CJh^h^5CJ h^CJ hsCJ h VCJ h*ECJ hR|CJh~x5CJaJhs5CJaJh)]5CJaJhi\5CJaJh#/h5CJaJh#/hR|5CJaJhsOJQJh#/hR|OJQJ,jh#/ha|CJOJQJUmHnHu %DE l m n $ % 3 4 >^`>gd+E^gdO@ ^`gd $a$gd^ $dNgd^ gd*E`gd*Egd*Egd+$a$gd)]$a$gd+gd+& ' + , 2 3 m n o r s ( * , - 4 6 7 > ? 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