GIM 10 - Exhibit 1

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GIM 10
Exhibit 1

Significant Financial Interest Disclosure Form

Instructions

Provide all information required in Parts I, II and III of this Significant Financial Interest Disclosure Form and obtain the recommending signatures indicated below. For detailed information on completing this form and the policy, procedures and definitions that apply, see GIM 10, Significant Financial Interest Disclosure Policy. An editable pdf version of this form is also now available.

Part I - Disclosing Person

Name:

School or College: Department or Other Unit:

This information is being submitted in connection with (check only one):

Research (complete Part II-A only)

Technology Transfer Transaction (complete Part II-B only)

Part II-A - Research (to be completed by Investigator)

Title:

Sponsored Research or Non-Sponsored Research (check one only)

Human Subjects Research: Clinical Trial Non-Clinical Trial (check only if applicable)

Part II-B - Technology Transfer Transaction (to be completed by UW TechTransfer)

Title:

Name of Transferee:

Brief Description of Transaction:

Part III - Disclosures

I am disclosing all Significant Financial Interests, if any, of myself and my Immediate Family Members related to the matters described in Part II-A or Part II-B above (i) that would reasonably appear to be affected by such Research or Technology Transfer Transaction, and (ii) that are in an Entity that would reasonably appear to be affected by such Research or Technology Transfer Transaction. (Complete either A or B)

A - Disclosure of Significant Financial Interest

A detailed description of the nature and amount of all Significant Financial Interests is included in the attached envelope marked "Confidential" and addressed to the Vice Provost for Research and consists of one or more of the following:

Compensation Interest (consulting fees, salaries, honoraria, etc.)
Equity Interest (stocks, options, share of profits, etc.)
Intellectual Property Interest (royalties, license fees, etc.)
Other Financial Interest (anything else of monetary or economic value)

B - No Disclosure Required

I have no Significant Financial Interest to disclose

I understand that the following are not considered Significant Financial Interests and are exempt from disclosure:

salary and other forms of non-royalty and non-equity compensation paid by the University
reasonable compensation paid by a public or nonprofit Entity in exchange for seminars, lectures or teaching engagements or for service on advisory committees or peer review panels
for non-Human Subjects Research and Technology Transfer Transactions, Financial Interests where the total aggregate value thereof is less than $10,000
for non-Human Subjects Research and Technology Transfer Transactions, an Equity Interest representing less than a 5% ownership interest in an Entity (unless the value of the Equity Interest, either separately or aggregated with other Financial Interests, is greater than $10,000)
for Human Subjects Research that is not a Clinical Trial, Compensation Interests whose total value does not exceed $5,000

I further agree:

to provide any additional information requested by the Office of Research
to cooperate in the development of an appropriate Management Plan as required by the Office of Research
during the period of any Research described in Part II-A above, to update this disclosure on an annual basis and to submit a disclosure of all new Financial Interests arising during the Research
to comply with all terms and conditions contained in any Management Plan
to take reasonable measures to ensure that any of my Financial Interests that are less than a Significant Financial Interest do not adversely influence any Research or any person involved in any Research in which I participate as an Investigator or any Technology Transfer Transaction

Signed: Date:
(Original Signature Required)

Recommendation for Approval

The undersigned have each reviewed the foregoing, but not any related confidential information provided to the Vice Provost for Research, and recommend that the Research or Technology Transfer Transaction, as the case may be, be approved on condition that any potential Conflicts of Interest related thereto be eliminated, reduced or otherwise adequately managed.

Department/Unit Head: Date:

School/College Dean: Date:

GIM 10 Exhibit 1

GIM 10
Exhibit 1