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: 
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