ࡱ> 9<6781 Tbjbj ;ZЅqhЅqhBf f HHH\\\84\w&d4%J%J%J%')$+uuuuuuu$z|TvYH+&&"++vJ%J%ow2111+vJ%8J%u1+u114j40pJ%@a,hl>uw<wl. }, }|pp }Hp++1+++++vv/D+++w++++ }+++++++++f X :  This form can be completed electronically in Microsoft Word, saved and e-mailed to  HYPERLINK "mailto:COI-compliance@andrew.cmu.edu" COI-compliance@andrew.cmu.edu. If you have questions, please email or call 412-268-5858. Instructions You have been identified as an Investigator who will be participating in a CMU research project as a subcontractor or consultant, or as a future CMU Investigator who is not currently able to use the SPARCS system to submit a disclosure. In order to comply with the  HYPERLINK "https://www.energy.gov/sites/default/files/2021-12/Interim%20COI%20Policy%20FAL2022-02%20to%20SPEs.pdf" Department of Energy Interim Conflict of Interest Policy, you must submit a financial interest disclosure to Carnegie Mellon. If you believe this does not apply to you, or if you have Significant Financial Interests of a type that this form is not designed to handle, please contact us at  HYPERLINK "mailto:COI-compliance@andrew.cmu.edu" COI-compliance@andrew.cmu.edu. Investigator Responsibilities As defined by this policy, Investigator means the Project Director, Principal Investigator or any other person, regardless of title or position, who is responsible for design, conduct or reporting of research funded or proposed for funding by the DOE. This includes all key personnel identified in the grant application, progress report or other report submitted to the funding agency by the Institution. The DOE may at its discretion expand the definition to include additional personnel for a particular proposal or award. DOE policy requires that recipients of research funding disclose certain financial interests to the university. As a DOE-funded Investigator, you are required to disclose certain financial relationships with external organizations. This includes remuneration received or ownership interests held by you, your spouse, or your dependent children that reasonably appear to be related to your responsibilities in regard to your research collaboration with CMU. Investigators are responsible for filing an accurate disclosure annually and within thirty (30) days of discovering or acquiring (through marriage, purchase, gift, inheritance, etc.) a new Significant Financial Interest. Your disclosure will be reviewed by CMUs Office of Research Integrity and Compliance (ORIC). If it appears that you may have a Financial Conflict of Interest, you will be contacted by someone from ORIC. At that point, you may be asked to provide additional details about your disclosed information. All Investigators must become familiar with DOE and CMU policies regarding Financial Conflicts of Interest in Research. Information is embedded in this disclosure form and available on  HYPERLINK "/research-compliance/conflict-of-interest/index.html" the CMU ORIC website. Consistent with DOE policy all DOE-funded Investigators must complete training on FCOI prior to spending on an award. This training does not need to be completed at time of proposal submission; ORIC will provide you with training material to review at time of award. Please refer to the following: CMU policies on HYPERLINK "http://www.cmu.edu/policies/administrative-and-governance/conflict-of-interest-commitment.html"Conflict of Interest and Commitment, HYPERLINK "http://www.cmu.edu/policies/research/compliance-financial-coi-research.html"Financial Conflicts of Interest in Research, and  HYPERLINK "/research-compliance/organizational-conflict-of-interest/documents/cmu-policy-oci-2016.pdf" Organizational Conflict of Interest HYPERLINK "/research-compliance/conflict-of-interest/documents/coi_guidelines.pdf"CMU Guidelines on Compliance with Financial Conflict of Interest Regulations HYPERLINK "http://www.cmu.edu/research-compliance/conflict-of-interest/index.html"CMU COI webpage Definitions This form is designed to help you disclose Significant Financial Interests (SFI) that reasonably appear to be related to your responsibilities in regard to your research collaboration with CMU. Significant Financial Interests (SFI) include certain payments, ownership interests, and intellectual property rights and interests. Remember, you need only disclose these financial relationships if they reasonably appear to relate to your responsibilities in your collaboration with CMU, as described below. You should disclose relationships with both U.S. and foreign entities. What should be disclosed depends on a number of factors. SFI includes and you should disclose: Your salary from your home institution, if the work you do there is related to the work you will do in collaboration with CMU. (For consultants, it may be unrelated.) Financial ties with publicly traded companies if the value of any compensation or payment in the preceding 12 months, plus the value of any equity interest as of the date of this disclosure, exceeds $5,000. This includes salary, payment for services, stock, stock options or other ownership interest. For example, if Acme paid you $3,000 for consulting and you own $1,000 of Acme stock, you need not disclose this. However, if you were paid $3,000 for consulting and own $2,500 of stock, you should disclose as the aggregated amount exceeds $5,000. Financial ties with private entities not publicly traded, if you have any equity such as stock, stock options, or other ownership regardless of dollar value. Additionally, you should disclose any compensation or payment in the preceding 12 months which exceeds $5,000. Income from intellectual property rights and interests such as patents and copyright, upon receipt of income, where the payments are not from Carnegie Mellon and exceed $5,000. SFI does not include (so you need not disclose): Salary, royalties, or other payments from Carnegie Mellon; Investments such as mutual funds where you do not directly control investment decisions; Income from seminars, lectures, or teaching engagements sponsored by a U.S. government agency, institution of higher education, academic teaching hospital, medical center or research institute affiliated with a U.S. institution of higher education. You must disclose these forms of income if they come from a non-U.S. institution. Income from service on an advisory committee or review panel for a U.S. government agency, institution of higher education, academic teaching hospital, medical center, or research institute affiliated with a U.S. institution of higher education. You must disclose these forms of income if they come from a non-U.S. institution. For purposes of this disclosure,  you means you and your immediate family (spouse, domestic partner, or dependent child). Contact Information Full Name of Individual Making this Disclosure:  FORMTEXT      Home Institution:  FORMTEXT      E-mail:  FORMTEXT      Telephone:  FORMTEXT      Name of Carnegie Mellon research partner(s):  FORMTEXT      Title of the research proposal on which you are partnering with CMU:  FORMTEXT       Please list below any additional individuals at your institution who are participating in this research collaboration with CMU who are Key Personnel or otherwise responsible for the design, conduct or reporting of this research proposal. We will contact these individuals and ask them to complete a disclosure as well. Name:  FORMTEXT      Research role:  FORMTEXT      E-mail address:  FORMTEXT      Name:  FORMTEXT      Research role:  FORMTEXT      E-mail address:  FORMTEXT      Name:  FORMTEXT      Research role:  FORMTEXT      E-mail address:  FORMTEXT      Name:  FORMTEXT      Research role:  FORMTEXT      E-mail address:  FORMTEXT      D.1. Relationships with Publicly Traded Entities  FORMCHECKBOX  Yes  FORMCHECKBOX No I (or my spouse, domestic partner, or dependent children) have an ownership interest in a publicly traded entity that reasonably appears to be related to my responsibilities in regard to my research collaboration with CMU.  FORMCHECKBOX  Yes  FORMCHECKBOX No I (or my spouse, domestic partner, or dependent children) have received payments or compensation exceeding $5,000 from a publicly traded entity in the last twelve (12) months that reasonably appears to be related to my responsibilities in regard to my research collaboration with CMU. If you answered yes to either of the preceding questions, please continue below. Otherwise, proceed to section D.2. Provide details below regarding the type of relationship you have with each privately held entity which meets either of the above criteria. Attach additional pages if necessary.Name of publicly traded external entity:  FORMTEXT       Does total for this entity over the past 12 months exceed $5,000?  FORMCHECKBOX  Yes  FORMCHECKBOX No Type of Financial Interest (check all that apply) Comments Stock  FORMCHECKBOX  Yes  FORMTEXT       Stock options  FORMCHECKBOX  Yes Other form of ownership  FORMCHECKBOX  Yes Payment for consulting or advising  FORMCHECKBOX  Yes Payment for serving on the Board  FORMCHECKBOX  Yes Payment for speaking engagement(s)  FORMCHECKBOX  Yes Payment for editorial services  FORMCHECKBOX  Yes Payment for other roles/services  FORMCHECKBOX  Yes Royalties related to Intellectual Property  FORMCHECKBOX  Yes Name of publicly traded external entity:  FORMTEXT       Does total for this entity over the past 12 months exceed $5,000?  FORMCHECKBOX  Yes  FORMCHECKBOX No Type of Financial Interest (check all that apply) Comments Stock  FORMCHECKBOX  Yes  FORMTEXT       Stock options  FORMCHECKBOX  Yes Other form of ownership  FORMCHECKBOX  Yes Payment for consulting or advising  FORMCHECKBOX  Yes Payment for serving on the Board  FORMCHECKBOX  Yes Payment for speaking engagement(s)  FORMCHECKBOX  Yes Payment for editorial services  FORMCHECKBOX  Yes Payment for other roles/services  FORMCHECKBOX  Yes Royalties related to Intellectual Property  FORMCHECKBOX  Yes D.2. Relationships with Privately Held Entities  FORMCHECKBOX  Yes  FORMCHECKBOX No I (or my spouse, domestic partner, or dependent children) have an ownership interest in a privately held entity that reasonably appears to be related to my responsibilities in regard to my research collaboration with CMU.  FORMCHECKBOX  Yes  FORMCHECKBOX No I (or my spouse, domestic partner, or dependent children) have received payments or compensation exceeding $5,000 from a privately held entity in the last twelve (12) months that reasonably appears to be related to my responsibilities in regard to my research collaboration with CMU. If you answered yes to either of the above questions, please continue below. Otherwise, proceed to section E. Provide details below regarding the type of relationship you have with each privately held entity meeting the criteria above. Attach additional pages if necessary.Name of privately held external entity:  FORMTEXT       Type of Ownership Interest Yes Comments Stock  FORMCHECKBOX  Yes  FORMTEXT       Stock options  FORMCHECKBOX  Yes Other form of ownership  FORMCHECKBOX  Yes Does total for this entity over the past 12 months exceed $5,000?  FORMCHECKBOX  Yes  FORMCHECKBOX No Type of Payment (Check all that apply) Comments Payment for consulting or advising  FORMCHECKBOX  Yes  FORMTEXT       Payment for serving on the Board  FORMCHECKBOX  Yes Payment for speaking engagement(s)  FORMCHECKBOX  Yes Payment for editorial services  FORMCHECKBOX  Yes Payment for other roles/services  FORMCHECKBOX  Yes Royalties related to Intellectual Property  FORMCHECKBOX  Yes Name of privately held external entity:  FORMTEXT       Type of Ownership Interest Yes Comments Stock  FORMCHECKBOX  Yes  FORMTEXT       Stock options  FORMCHECKBOX  Yes Other form of ownership  FORMCHECKBOX  Yes Does total for this entity over the past 12 months exceed $5,000?  FORMCHECKBOX  Yes  FORMCHECKBOX No Type of Payment (Check all that apply) Comments Payment for consulting or advising  FORMCHECKBOX  Yes  FORMTEXT       Payment for serving on the Board  FORMCHECKBOX  Yes Payment for speaking engagement(s)  FORMCHECKBOX  Yes Payment for editorial services  FORMCHECKBOX  Yes Payment for other roles/services  FORMCHECKBOX  Yes Royalties related to Intellectual Property  FORMCHECKBOX  Yes OtherDo you have any financial interests or family relationships that you believe create an actual or perceived conflict of interest with your work on this research project?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please describe.  FORMTEXT       Sponsored or Reimbursed Travel - Complete only if you currently have an subaward or consulting agreement from DOE through CMU If you are completing this form at the time of a proposal submission and do not yet have a subcontract or consulting agreement the DOE through CMU, skip this section and move on to section G. Your obligation to report travel will begin when an award is made. The DOE requires that all recipients of DOE funding disclose all travel that is paid for on their behalf or for which they are reimbursed. This requirement does not apply to travel sponsored by a U.S. federal, state or local government, a U.S. institution of higher education, a U.S. academic teaching hospital or a U.S. research institute affiliated with an institution of higher education. This travel is exempt and does not have to be reported Please list all such travel within the previous twelve (12) months below. In the future, you are to disclose such travel to the CMU COI office within thirty (30) days of its completion. 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You will not need to disclose this travel again within 30 days of completion, unless the information changes.SponsorPurposeDestinationDates of Travel FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Signature & Certification Please acknowledge your understanding by checking the four boxes below. You will need to enter your name and title into the final statement.  FORMCHECKBOX  I understand that at the time the award is made, I must complete an online conflict of interest training before I can receive any funds.  FORMCHECKBOX  I understand that I am to comply with ĢAvs policies related to Financial Conflict of Interest and research for the work completed in collaboration with CMU. As a researcher receiving federal funds, I understand that I have an obligation to adhere to applicable federal regulations regarding Financial Conflict of Interest.  FORMCHECKBOX  To the best of my knowledge, I have disclosed all of my financial relationships as required by CMU policy and federal regulations. I understand that I have a continuing responsibility to comply with these and update my disclosure as necessary.  FORMCHECKBOX  I understand that this Disclosure is required to obtain funding from the U.S. Government. I, [Enter full name and title:  FORMTEXT      ], certify to the best of my knowledge and belief that the information contained in this Disclosure Statement is true, complete, and accurate. I understand that any false, fictitious, or fraudulent information, misrepresentations, half-truths, or omissions of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims, or otherwise. (18 U.S.C. 1001 and 287, and 31 U.S.C. 3729-3730 and 3801-3812). I further understand and agree that (1) the statements and representations made herein are material to U.S. Governments funding decision, and (2) I have a responsibility to update the disclosures during the period of performance of the award should d$Ifgd_ qkda$$Ifl<' t0}644 lap yt_ 6^F8888d$Ifgd_ kda$$Ifl\g R=<' t0}644 lap(ytOX   $&(*,.02468LNPRTVXZ\^`tvxz|~ݳݥݗjweh_ hTUjeh_ hTUjch_ hTUjOch_ hTUjbh_ hTU h_ hTjh_ hTU jh_ hTUmHnHu;(F8888d$Ifgd_ kd;d$$Ifl\g R=<' t0}644 lap(ytOX "$&(*,@BDFHJLNPRThjlnprtvxz|ݳݥݗjhh_ hTUjhh_ hTUjgh_ hTUjcfh_ hTUjeh_ hTU h_ hTjh_ hTU jh_ hTUmHnHu;(*RzF8888d$Ifgd_ kdf$$Ifl\g R=<' t0}644 lap(ytOX            2 4 6 8 : < > @ B D F Z \ ^ ` b d f h j l n jkh_ hTUj)kh_ hTUjjh_ hTUj=jh_ hTU jh_ hTUmHnHujih_ hTUjh_ hTU h_ hT; D l F8888d$Ifgd_ kdwi$$Ifl\g R=<' t0}644 lap(ytOXl n  F4 & Fd$IfgdAxkdl$$Ifl\g R=<' t0}644 lap(ytOXn   !!2!N!Z!v!!!!!!!!!""F"|"~""""""#&#'#<#A#D#w#####$$w$$$$$%ҽҹҹ왮싮y h_ hH0jh_ hH0Ujsnh_ hTU(jmHhcGh_ h|YUjh_ hTUh"](jmHhcGh_ h"]U h_ h"]jh_ h"]UhThH0 h_ hTh_ hT5B* ph-  !!~""##$$Dwwiwwwww[d$IfgdH0d$Ifgd"]d$Ifgd_ zkdl$$Ifl<'  t 0}644 lap yt_ % % % % %X%Y%h%%%%%%&&&& & &&n&p&&&&''''(.(/(A(B(((((()).)/)s)t))))))D~DDDDDƶΤۢۛjh_ hTU h_ hTU#jhH0hH0>*UmHnHuj_ohH0hH0>*UhH0hH0>*jhH0hH0>*UhH0 h_ hH0jh_ hH0Ujnh_ hH0U7circumstances change which impact the responses provided above. Signature:  FORMTEXT      ____________________________________________________ Date:  FORMTEXT      ________________________________________________________ This form can be completed electronically in Microsoft Word, saved and e-mailed to  HYPERLINK "mailto:COI-compliance@andrew.cmu.edu" COI-compliance@andrew.cmu.edu. If you have questions please call 412-268-5858.     ĢAv Significant Financial Interest Disclosure (SFI) For External Collaborators of Researchers Supported by the Department of Enenrgy (DOE)  PAGE \* MERGEFORMAT 3 June 2022 ĢAv Significant Financial Interest DisclosureDDDDDDDDD,E.E:E $a$gd_;$a$gd#2$a$gdvL. $a$gd} $a$gd8J dgdPQGGGGGGGGGGGT"T$T,T5B* phUh1hG5B* phhG5B* phhY hG5B* ph&jhG5B* UmHnHphuhGh93hGCJaJmHnHuhH0CJaJmHnHuhvL.hGCJaJmHnHu (SFI) for External Collaborators Research Complying With Department of Enenrgy (DOE) Conflict of Interest Regulations [Type here] Received: No: TTTTTTTTTTgdgd_; TTTThhCJaJh hG9 0&P1h:p_;/ =!"#$%@  $$If!vh#v':V l  t 0}65ap yt_ CDyK yK https://www.energy.gov/sites/default/files/2021-12/Interim COI Policy FAL2022-02 to SPEs.pdfyX;H,]ą'c$$If!vh#v':V l t0}65ap yt_ $$If!vh#v':V l  t 0}65ap ytDyK yK https://www.cmu.edu/research-compliance/conflict-of-interest/index.htmlyX;H,]ą'cGDyK yK http://www.cmu.edu/policies/administrative-and-governance/conflict-of-interest-commitment.htmlyX;H,]ą'c!DyK yK 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