Guide to Ad Hoc Conflict of Interest Disclosures

This format has been developed by the offices of the Dean of Research and Technology Licensing, working with representatives from several Schools. It is intended for use by any individuals whose situation requires an ad hoc disclosure of a relationship which could create a conflict of interest.

Comments may be directed to the Director, Office of Technology Licensing.

Introduction

The University has conflict of interest policies for faculty, academic staff, staff, and students/postdocs. Included in these policies are requirements for all faculty members to certify to their school deans on an annual basis their compliance with Stanford's policies related to conflict of interest and commitment, and to disclose their prior academic year's consulting activities for and/or significant financial interests in outside organizations that support their University teaching or research program.

In addition, individuals are also required to disclose on an ad hoc basis proposed relationships with outside entities that may lead to conflicts of interest. "Ad hoc" disclosures are called for whenever a current or prospective relationship creates the potential for conflicts of interest. For information on what situations require conflict of interest disclosure, check the policies listed below that apply to you:

• Faculty Policy on Conflict of Commitment and Interest
  http://rph.stanford.edu/4-1.html
• Annual Faculty Certification and Disclosure Format
  http://coi.stanford.edu/
• Conflict of Commitment and Interest for Academic Staff
  http://rph.stard.edu/4-4.html
• Staff Policy on Conflict of Commitment and Interest
  http://adminguide.stanford.edu/15_2.pdf [pdf file]
• Relationships between Students (including Postdoctoral Scholars) and Outside Entities
  http://rph.stanford.edu/2-11.html
• Inventions, Patents and Licensing
  http://rph.stanford.edu/5-1.html
• Copyright Policy
  http://rph.stanford.edu/5-2.html

To facilitate assessment of any perceived or actual conflicts of interest that your activities might create with your University responsibilities, we suggest that you provide the information requested in the Ad Hoc Disclosure Template below. If preferred, you may submit a letter and use this form as a guide. Please submit either document to the appropriate individual(s) as specified in the policy that applies to you. If the proposed arrangement involves a current or potential licensing agreement, please send a copy of your disclosure to the Office of Technology Licensing (OTL). OTL will not be able to conclude any agreements until the appropriate conflict of interest reviews and approvals have been completed.

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The format below is available as a downloadable Word file. You may download it to your desktop and complete it using Word.

Ad Hoc Disclosure Template

Your name __________________________________________

Date _______________________________________________

1. Name of company with which there is a proposed relationship:
   
   
   
   
   
2. Nature of the relationship either EXISTING or PROPOSED. Please check ALL that apply, i.e., if you are currently a founder and a consultant proposing to receive gift funds, you would check both of the appropriate boxes under EXISTING and the gift box under PROPOSED, and enter the amount (in $ or % equity) of financial interest of each.
   
   

Relationship/ activities	EXISTING	PROPOSED	Amount ($ or %) of financial interest
Founder
Employee/ Executive Position
Scientific Advisory Board
Consultant
Stock or Ownership Interest
Gift
Sponsored Project
Licensor of Technology
Clinical Trial
Other

 

3. If you checked either EXISTING or PROPOSED for Sponsored Research, Gift, or Clinical Trial, please answer the appropriate Q1 questions below:
   1. Is the sponsored research being conducted for regulatory approval or does it use a technology licensed to the sponsor? Please explain.
      
      
      
      
   2. How do you intend to use the gift funds? Please explain.
      
      
      
      
   3. Is the Clinical Trial testing your own invention or the company's own products? Please explain.
      
      
      
      
4. What is your role in the proposed activity or relationship (e.g., PI of study, co-investigator, organizer of CME, etc.)? Please explain.
   
   
   
   
5. Who else will be involved in the activity (students, postdoctoral fellows, etc.) and how?
   
   
   
   
6. How might the proposed relationship affect your Stanford research, including the research projects of your students and postdocs?
   
   
   
   
7. Education and training of students is one of the University's highest priorities. Therefore, the research and scholarship of students and other trainees should be protected from any consequences of faculty relationships with outside entities.
   
   Please explain how you intend to separate any potential conflicts between your University responsibilities (including your research at Stanford, students, postdocs, etc.) and your proposed activities with the commercial entity.

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