Ad Hoc Outside Interest Disclosure Form
An Outside Interests Disclosure Form is required for all persons applying for or receiving funding from external sponsors for research projects or from EMU internal awards. Disclosure Forms will be evaluated for potential conflicts of interest, conflicts of commitment, and international activities. If you need assistance completing the Outside Interests Disclosure Form, contact the Office of Research Compliance at (734) 487-3090 or research_compliance@emich.edu. You can refer to the EMU Conflict of Interest policy on the Research Compliance website.
Name
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First Name
Last Name
Emich E-mail
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example@example.com
Work Information
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Title/Role
Department
Phone Number
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-
Area Code
Phone Number
Who is your direct supervisor? In the event of a declared outside interest, your direct supervisor may need to approve the management plan.
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First Name
Last Name
Supervisor Email
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example@example.com
Please describe the funding source. For EXTERNAL sources please list the funding agency or foundation. For INTERNAL (EMU or EMU Foundation) sources, please list the name of the internal award program you are applying to.
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What is the title of this project?
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For external projects, enter the Cayuse SP proposal number (e.g. 26-0123). For internal awards, please enter the award program (e.g., Brickley, FRF, SRA, etc.).
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What percentage of your time in the current year of the project will be devoted to this project?
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Information about this form
A research conflict of interest disclosure form typically asks individuals to report any financial, personal, or professional relationships that could influence—or appear to influence—their research. This may include:💰 Payments or income from outside entities (e.g., consulting fees, honoraria)📈 Equity interests in companies related to the research🧑🤝🧑 Relationships with sponsors, collaborators, or vendors🏥 Roles in organizations that could benefit from the research outcomes👨👩👧👦 Financial interests held by spouses, dependent children, or qualifying adults. The goal is transparency—to ensure research remains unbiased and trustworthy.
Disclosure:
For the purpose of this disclosure, Institutional Responsibilities mean an Investigator’s professional responsibilities associated with his or her Institutional appointment or position, such as research, teaching, clinical activities, administration, and institutional, internal and external professional committee service.
Publicly Traded Entity:
A company that has issued securities (stock/shares, bonds/loans, etc.) through an offering, which are now traded on the open market (opposite of a private company).
Entity:
Any domestic or foreign, public or private, organization (excluding a Federal agency) from which an Investigator (and spouse and dependent children) receives remuneration or in which any person has an ownership or equity interest.
Qualifying Adult:
An individual—other than yourself or your spouse—who is 18 years or older, part of your household or financially connected in a way that may present a conflict of interest, capable of receiving income or payments that must be disclosed. This could include adult children, domestic partners, or other adults whose financial interests are relevant to your disclosure. The term is used to ensure that disclosures capture not just your own financial relationships, but also those of others whose interests might reasonably affect or be affected by your research activities.
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Publicly Traded Entity
Have you or your spouse, additional qualifying adults, and/or dependent children received income or payment for services for the past 12 months exceeding $5,000 when aggregated in any Publicly Traded Entity? This does not include interests in mutual funds and retirement funds in which you do not directly control investment decisions. This does not include income from seminars, lectures, or teaching engagements sponsored by a U.S. federal, state, or local government agency, a U.S. institution of higher education or an affiliated research institute, an academic teaching hospital, or a medical center.
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Yes
No
If yes, please state name of entity.
If yes, please provide a description of income.
Intellectual Property Rights and Interests
Have you or your spouse, additional qualifying adults, and/or dependent children received any payments, in the past 12 months, for any intellectual property rights and interests (e.g. patents, copyrights, assigned or licensed to a party other than EMU)?
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Yes
No
Please provide a description of intellectual property rights and interests.
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Travel Reimbursement/Scholarship
Have you received travel reimbursement or been sponsored for travel (i.e. travel expenses paid on behalf of Investigator and not reimbursed to Investigator) in the 12 months prior to disclosure, by any entity related to your institutional responsibilities? This does not include travel reimbursed or sponsored by U.S. Federal, state or local governmental agencies, U.S. institutions of higher education, research institutes affiliated with institutions of higher education, academic teaching hospitals, and medical centers, unless that entity is itself the subject of research by the Investigator.
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Yes
No
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Non-Publicly Traded Entity Interests
Have you or your spouse, additional qualifying adults, and/or dependent children received income or payment for services for the past 12 months exceeding $5,000 when aggregated in any Publicly Traded Entity? This does not include interests in mutual funds and retirement funds in which you do not directly control investment decisions. This does not include income from seminars, lectures, or teaching engagements sponsored by a U.S. federal, state, or local government agency, a U.S. institution of higher education or an affiliated research institute, an academic teaching hospital, or a medical center.
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Yes
No
If yes, please state name of entity.
If yes, please provide a description of income.
Equity Interests
Do you or your spouse, additional qualifying adults, and/or dependent children currently own, or have acquired in the past 12 months, any equity interest in any non-publicly traded entity related to your institutional responsibilities? This can include any stock, stock option, or other ownership interest.
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Yes
No
Please provide a description of equity interests.
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Outside Commitments
Do you currently have any additional outside employment or commitment(s) similar or overlapping in nature to your responsibilities at EMU (e.g., academic appointments, teaching, research/scholarship, professional service) or that relies on your specific professional expertise (e.g., consulting, advising, etc.)? Include both international and domestic commitments. Only include situations in which you are receiving compensation, support, resources, or anything else of value in return.
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Yes
No
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For whom will the work be done?
Name of organization
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Is the outside employer another college or university?
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Yes
No
Does this work involve a consulting agreement?
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Yes
No
In what country will this work be conducted?
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Briefly describe the nature of the work you will be doing.
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Do you have additional outside commitments to report in this section?
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Yes
No
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For whom will the work be done?
Name of organization
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Is the outside employer another college or university?
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Yes
No
Does this work involve a consulting agreement?
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Yes
No
In what country will this work be conducted?
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Briefly describe the nature of the work you will be doing.
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Do you have additional outside commitments to report in this section?
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Yes
No
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For whom will the work be done?
Name of organization
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Is the outside employer another college or university?
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Yes
No
Does this work involve a consulting agreement?
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Yes
No
In what country will this work be conducted?
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Briefly describe the nature of the work you will be doing.
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International Interests
Do you have any foreign or international collaborators for your research/scholarship/creative activity?
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Yes
No
Do you currently have any other professional interests or affiliations, with a university or otherwise, in another country?
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Yes
No
Do you currently receive or plan to receive any funding or compensation from another country’s government, or are you involved in a foreign talent program?
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Yes
No
Please provide additional information about international collaborations including who you collaborated with, what country they are from, what is the nature of the collaboration, where you travelled, and what specific compensation you've received from foreign entities.
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Gifts
Gifts can include, but are not limited to, voluntary transfers of value—including cash, donations, in-kind materials, equipment, or facility access—provided without expectation of direct compensation or services.
Have you received any gifts related to your work that have not been addressed in other sections of this form?
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Yes
No
Please provide a description of gifts received.
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Certification
By submitting this form, I certify that all of the information is correct to my knowledge.
Submit
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