Conflict of Interest (COI) Reporting Form - Modules, Course, Clerkship, and Acting Internships

Conflict of Interest (COI) Reporting Form - Modules, Course, Clerkship, and Acting Internships

The purpose of this form is to document in a central location the interventions taken by the modules, courses acting internships, and clerkships to address any reported COI from educators and/or students. This form should be completed for each reported COI.
Your Email*
Name of person completing this form*

First NameLast Name
ASCEND Phase 1
LEGACY Year 2 Courses
LEGACY Year 3 and 4 Clerkship/Acting Internship/Courses
Identify the name of the faculty/student who reported a COI*

First NameLast Name
Date of Reported COI

MonthDayYear
Date
Please describe the interventions taken to address the conflict of interest reported (e.g reassigned the educator/student, adjusted schedules, others)*
Should be Empty: