THW Financial Conflict of Interest (FCOI) Disclosure Form

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THW FCOI Form_27May2025.docx (66.1 KB)

Purpose

  • Ensures compliance with PHS regulations (42 CFR Part 50 & 45 CFR Part 94) on promoting objectivity in research.
  • Requires disclosure of Significant Financial Interests (SFIs) related to research responsibilities.

Who Must Complete

  • All personnel responsible for design, conduct, or reporting of research, regardless of funding source.
  • Includes PIs, Co-PIs, research staff, collaborators, and consultants.

Key Requirements

  • Review Trinity Health–West Region’s Objectivity in Research policy.
  • Complete FCOI training every 4 years.
  • Submit disclosure for:
    • Initial, Annual, or New/Updated situations.
  • Disclose SFIs related to:
    • Publicly traded and non-publicly traded entities.
    • Non-profit entities.
    • Travel reimbursements.
    • Intellectual property rights.
    • Foreign components and other support.

Form Sections

  1. Investigator & Research Information
  • Full name, title, hospital, department, contact info.
  1. Type of Disclosure
  • Initial / Annual / Updated.
  1. Role in Clinical Research
  • PI, Co-PI, Coordinator, Biostatistician, etc.
  1. Funding Source
  • Identify if research is funded by PHS agencies (e.g., NIH).

Process

  • Submit completed form to Research Compliance Department.
  • Conflict of Interest Committee reviews and manages any identified FCOIs.