Disclosures: Do you, your spouse/domestic partner, or your dependents hold an interested position (e.g. senior administrative official, of Directors membership, Advisory Committee, etc.) within the St. Joseph Health organization that involves any of the following: Licensing, technology transfer, patents Investments of the organization Gifts to the organization when the donor has an interest in the research Financial interests of senior administrators, directors, or similar positions Other financial interests No Yes, Explain: Do you, your spouse/domestic partner, or your dependents hold any collaboration agreements with commercial entities (i.e. professional or academic collaborations) that may have financial implications? No Yes, Explain: Do you, your spouse/domestic partner, or your dependents have any personal interest or involvement with or non-commercial research organizations and or research interest no indicated above that could pose or be perceived as a conflict? No Yes, Explain: I have read and agree to abide by the policies which govern Financial Conflicts of Interest in Research as established by the St. Joseph Health organization and the IRB. I also agree to submit on an Ad Hoc basis disclosures that would constitute a financial interest as indicated above. Signature Date Printed name
Disclosures: Do you, your spouse/domestic partner, or your dependents hold an interested position (e.g. senior administrative official, of Directors membership, Advisory Committee, etc.) within the St. Joseph Health organization that involves any of the following: Licensing, technology transfer, patents Investments of the organization Gifts to the organization when the donor has an interest in the research Financial interests of senior administrators, directors, or similar positions Other financial interests No Yes, Explain: Do you, your spouse/domestic partner, or your dependents hold any collaboration agreements with entities (i.e. professional or academic collaborations) that may have financial implications? No Yes, Explain: Do you, your spouse/domestic partner, or your dependents have any personal interest or involvement with commercial or non-commercial research organizations and or research interest no indicated above that could pose or be perceived as a conflict? No Yes, Explain: I have read and agree to abide by the policies which govern Financial Conflicts of Interest in Research as established by the St. Joseph Health organization and the IRB. I also agree to submit on an Ad Hoc basis disclosures that would constitute a financial interest as indicated above. Signature Date Printed name
Covenant_Medical_Center_Steps_IRB_Approval-4.2017.docx