Faculty Information Disclosure Form

Faculty Information Disclosure Form

Recitals

WHEREAS, the undersigned faculty member holds an academic appointment with the institution and, as a condition of that appointment, is required to disclose certain external financial interests, professional engagements, and other activities that may create real or perceived conflicts of interest;

WHEREAS, the institution requires accurate and timely disclosures to enable review, monitoring, and, where necessary, management of potential conflicts to protect the integrity of teaching, research, and institutional stewardship;

WHEREAS, the undersigned acknowledges the continuing obligation to update disclosures and to comply with institutional policies and any conflict-management measures imposed by authorized institutional officials.

Faculty Information

Employee ID:    Department:

Title / Rank:    Appointment Type: Tenured Tenure-Track Adjunct Visiting

Email:    Phone:

Disclosure Period

Beginning (Month/Year):       Ending (Month/Year):   

Categories of Disclosure

Check all categories that apply to any activity, role, or financial interest you hold or held during the Disclosure Period. For each checked category, provide the requested details below.

Details of Disclosed Activities

Conflict Management and Acknowledgments

Has this disclosed relationship previously been approved by the institution or a designated review committee? Yes No

I certify that the information provided in this Faculty Information Disclosure Form is true, complete, and accurate to the best of my knowledge. I understand that I have an ongoing duty to update this disclosure promptly when material changes occur and, in any event, within thirty (30) days of any material change.

I understand that failure to disclose required information or submission of materially false information may result in administrative action, including but not limited to management of conflicts, restrictions on activities, disciplinary action up to and including termination, and referral to appropriate regulatory or legal authorities where warranted.

Confidentiality

The institution will treat the submitted information as confidential to the extent permitted by applicable law and institutional policy. The institution may disclose disclosed information to authorized officials, review committees, funding agencies, and others as necessary to evaluate, manage, or report potential conflicts of interest. Information that is required to be disclosed under law or under funding agency requirements may be shared in accordance with those obligations.

Governing Law and Entire Agreement

This Disclosure Form shall be governed by and construed in accordance with the laws of the state in which the institution is located, without regard to conflict-of-law principles. This Form constitutes the complete and exclusive statement of the disclosure obligations addressed herein and supersedes any prior communications or representations, whether oral or written, concerning the matters disclosed.

Term and Withdrawal of Disclosure

This disclosure remains effective for the Disclosure Period stated above and for any subsequent period during which any disclosed interest is active. The undersigned may amend or withdraw this disclosure at any time by submitting a written amendment to the appropriate institutional official. Notice of a withdrawal or amendment must be provided in writing and will be effective upon receipt by the institution.

Certification and Signature

By signing below, I confirm that I have read and understood my obligations under institutional policies governing conflicts of interest and external activities, and that the foregoing statements are complete and accurate to the best of my knowledge.

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