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Clinical Research
Updated September 10, 2007
Conflict Of Interest Statement For DSMB Members
Confidential
Title
Dr. XX, Principal Investigator
Site
Grant Number ###
As noted below:
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I am not a part-time, full-time, paid, or unpaid employee of any organizations that are: (a) involved in the study under review; (b) whose products will be used or tested in the study under review, or whose products or services would be directly and predictably affected in a major way by the outcome of the study;
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I am not an officer, member, owner, trustee, director, expert advisor, or consultant of such organizations.
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I do not have any financial interests or assets in any organizations meeting the above criteria, not does my spouse, dependent children, nor any organization with which I am connected; and
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I am not a current or past collaborator or associate of the principal investigator.
Having read the above: (please check the appropriate answer)
___ I have no relevant interests or activities.
___ I have noted any expcetions in the
space below:
I will notify the NIAMS promptly if:
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a change occurs in any of the above during the tenure of my responsibilities, or
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I discover that an organization with which I have a relationship meets the criteria for a conflict of interest.
I am aware of my responsibilities for maintaining the confidentiality of any non-public information that I receive or become aware of through this activity, and for avoiding using such information for my personal benefit, the benefit of my associates, or the benefit of organizations with which I am connected or with which I have a financial involvement.