Funding

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:

  • 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;

  • I am not an officer, member, owner, trustee, director, expert advisor, or consultant of such organizations.

  • 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

  • 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:

  • a change occurs in any of the above during the tenure of my responsibilities, or

  • 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.