Conflict of Interest Statement Collection Form - Old - Global Genomic Medicine Consortium

GGMC Leadership Conflict of Interest Reporting

The Global Genomic Medicine Collaborative collaborates with leadership, staff, and external organizations to ensure quality review, management, and reporting of conflicts of interest related to activities within GGMC, including financial conflicts of interest related to sponsored research within GGMC programs.

For questions about COI management, please contact COI@g2mc.org.

Conflict of Interest Statement Collection Form

Personal Information

First Name

Middle Name

Last Name

Mobile Phone Number

Position within GGMC (check all that apply)

GGMC BoD

G2MC Executive Committee

G2MC Steering Committee

IHCC Executive Committee

IHCC Steering Committee

G2MC Co-Chair

IHCC Co-Chair

BoD Governance Committee

BoD Advisory Committee

BoD Development Committee

Secretariat

External Institution/Affiliation

Primary Position at External Institution/Affiliation

Assessments

What do I need to report on this form?

GGMC requires disclosure of any outside interests, activities, or relationships that relate or are similar to your GGMC work, area, or scholarship. Paid and unpaid activities (including any affiliations and employment) should be disclosed. Additionally, Significant Financial Interest (SI) should be disclosed. SI in this case, as a summary, is anything that exceeds $5,000 (salary, consulting fees, honoraria, paid authorship, equity, IP rights and interest, and travel reimbursement).

For more information, please check Research Financial Conflict of Interest Policy (PDF) document.

Disclosure is NOT REQUIRED for the following activities/financial interests:Ownership of a share in a mutual fund

Salary or other remuneration from an accredited U.S. institution of higher Education
Salary or other remuneration from the U.S. Department of Veterans Affairs or another federal, state, or U.S. local government entity, or other global government entity
Book Royalties
Ownership of a share in a mutual fund

Based on the information provided above, do you have an outside interest or activity to tell us about? (You can submit up to 5 Conflicts of Interest)

Yes

Outside Interests

Special Instructions

Outside professional interests/activities are non-GGMC activities within a faculty member or employee’s area of professional and/or academic expertise, whether paid or unpaid, and whether the company/organization/entity is for profit, not-for-profit, or non-profit.

You/Your = refers to you or any immediate family member (as applicable).

Current refers to the following time period = did have in calendar year <current year> or anticipate having in calendar year <next year>. Please disclose your current outside professional interests/activities below:

Name of entity/organization of outside interest/activity

Do you participate in GGMC-related research that is in any way related to this outside entity?

What is your role with this outside entity?

Describe your role

Do you receive any additional support or resources from this outside entity?

Are you listed as an inventor on any Intellectual Property patents, options or licenses held by this entity

Do you expect to continue this relationship in the future?

Do you have another outside interest to declare (#2)?

Yes

Please disclose your #2 outside professional interests/activities below:

Name of entity/organization of outside interest/activity (#2)

Do you participate in GGMC-related research that is in any way related to this outside entity? (#2)

What is your role with this outside entity? (#2)

Describe your role (#2)

Do you receive any additional support or resources from this outside entity? (#2)

Are you listed as an inventor on any Intellectual Property patents, options or licenses held by this entity (#2)

Do you expect to continue this relationship in the future? (#2)

Do you have another outside interest to declare (#3)?

Yes

Please disclose your #3 outside professional interests/activities below:

Name of entity/organization of outside interest/activity (#3)

Do you participate in GGMC-related research that is in any way related to this outside entity? (#3)

What is your role with this outside entity? (#3)

Describe your role (#3)

Do you receive any additional support or resources from this outside entity? (#3)

Are you listed as an inventor on any Intellectual Property patents, options or licenses held by this entity (#3)

Do you expect to continue this relationship in the future? (#3)

Do you have another outside interest to declare (#4)?

Yes

Please disclose your #4 outside professional interests/activities below:

Name of entity/organization of outside interest/activity (#4)

Do you participate in GGMC-related research that is in any way related to this outside entity? (#4)

What is your role with this outside entity? (#4)

Describe your role (#4)

Do you receive any additional support or resources from this outside entity? (#4)

Are you listed as an inventor on any Intellectual Property patents, options or licenses held by this entity (#4)

Do you expect to continue this relationship in the future? (#4)

Do you have another outside interest to declare (#5 Last One)?

Yes

Please disclose your #5 outside professional interests/activities below:

Name of entity/organization of outside interest/activity (#5)

Do you participate in GGMC-related research that is in any way related to this outside entity? (#5)

What is your role with this outside entity? (#5)

Describe your role (#5)

Do you receive any additional support or resources from this outside entity? (#5)

Are you listed as an inventor on any Intellectual Property patents, options or licenses held by this entity (#5)

Do you expect to continue this relationship in the future? (#5)

Other Matters

Do you make or influence personnel actions for, or supervise any immediate or extended family member within GGMC? If yes, please explain

Have you or will you engage in any government relations activities either representing GGMC or using GGMC’s resources? If yes, please explain

As a part of your official duties at GGMC, do you interact with foreign government officials or foreign political parties in order to obtain or retain a business relationship? If yes, please explain

Are there any other related matters of which you wish to make GGMC aware? (as with most conflict of interest issues, the appearance of influence or potential influence is important to consider when deciding what might create a conflict)

Affirmation

By typing my name below, I understand and agree that this form of electronic signature has the same implications as a manual signature and that the information entered is correct.

Global Genomic Medicine Consortium (G2MC)

GGMC Leadership Conflict of Interest Reporting

G2MC is a program of the Global Genomic Medicine Collaborative (GGMC)

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