Mid Month Departmental Submission

IRB Conflict of Interest Form
Thank you for taking the time to engage with Mid Michigan College's Institutional Review Board (IRB). The IRB is responsible for reviewing all research projects submitted by College personnel to ensure the protection of human subjects' rights and welfare, and ensures that risks related to research are assessed and minimized, potential benefits are identified, participation is voluntary as demonstrated by informed consent, and confidential information is safeguarded.

Use this form to disclose a conflict of interest after initial IRB approval.

Questions? Email ir@midmich.edu for guidance.

Project Information

Welcome! Let's begin with some basic information.
Enter the title of your research project.*
Provide the title of your research project.
Enter the IRB Reference Number of your research project.*
This number is typically a TBD digit number in the following structure TBD.
Researcher Name*

First NameLast Name
Role in the Research Project*
PI, SI, etc.
Researcher's Email*
example@midmich.edu
Researcher's Phone Number*

Area CodePhone Number

Let's learn more.

Share information with us about the conflict of interest. Describe any financial, personal, or professional relationships or interests that could influence the study’s conduct or results.
Financial Interests*
List any ownership, employment, consultancy, honoraria, or speaking arrangements that might constitute a financial conflict.
Personal Relationships*
Disclose any personal relationships or affiliations with sponsors, companies, or organizations relevant to the study.
Professional Affiliations*
Provide details of affiliations that may directly or indirectly impact the research's objectivity or ethical standards.
Outline steps to manage, reduce, or eliminate the conflicts of interest listed above.*
Be as detailed as possible.
Describe the procedures or strategies you propose for ongoing monitoring of identified conflicts.*
Be as detailed as possible.

I hereby certify that the information provided in this disclosure form is accurate and complete to the best of my knowledge. I agree to update this information promptly if my circumstances change and a new potential conflict arises during the research.

I understand that any identified conflict of interest must be managed according to institutional policies and IRB guidelines to maintain the research project’s integrity.
Signature of Researcher*

Clear
Date*

MonthDayYear
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For IRB Use Only

IRB Review Section
IRB Reviewer Name*

First NameLast Name
Reviewer Comments
Conflict Management Decision*

No ConflictManaged ConflictUnmanageable Conflict (Requires Further Action)
IRB Reviewer Signature*

Clear
Date*

MonthDayYear
Should be Empty:

IRB Conflict of Interest Form