PRINCIPAL INVESTIGATOR(S) (if applicable): PROJECT DIRECTOR(S) (if applicable): NATURE OF CONFLICT OF INTEREST all that apply): Equity interest _ Relationship (e.g., colleague, family member, etc.) Honorarium Consulting fee Travel reimbursement (please describe): VALUE OF FINANCIAL INTEREST (check one): Not applicable to this project/disclosure. $0-$4,999 $20,000-$100,000 $5,000-9,999 (indicate increment of $20,000) Over $100,000 _ (indicate increment of $50,000)
PRINCIPAL INVESTIGATOR(S) (if applicable): PROJECT DIRECTOR(S) (if applicable): NATURE OF CONFLICT OF INTEREST all that apply): Equity interest _ Relationship (e.g., colleague, family member, etc.) Consulting fee Travel reimbursement Honorarium (please describe): VALUE OF FINANCIAL INTEREST (check one): Not applicable to this project/disclosure. $0-$4,999 $20,000-$100,000 $5,000-9,999 (indicate increment of $20,000) _ Over $100,000 (indicate increment of $50,000)