East Carolina University Faculty Manual

APPENDIX I.

ECU POLICY ON CONFLICTS OF INTEREST AND COMMITMENT

Example Form B

REPORT OF ACTIVITIES AND RELATIONSHIPS WITH ENTERPRISES SPONSORING

UNIVERSITY ACTIVITIES OR DOING BUSINESS WITH THE UNIVERSITY

Faculty responding affirmatively to one or more of Questions 1-6 on the Annual Faculty Report of Potential Conflict of Interest Activities or Relationships form must complete the reporting process by providing the information requested below. If additional space is needed attach separate sheets labeled "REPORT OF ACTIVITIES AND RELATIONSHIPS WITH ENTERPRISES SPONSORING UNIVERSITY ACTIVITIES OR DOING BUSINESS WITH THE UNIVERSITY Continued" and note the answer number for which additional information is provided. A separate form should be used to report relationships with each enterprise or corporation.

_________________________ _____________________ __________________ _____________

Employee Name Department College/School Reporting Period

_________________________________________________________________________________

If reporting for an immediate family member, give his or her name and relationship.

____________________________ ______________________________________________

Enterprise/Corporation Name Complete Address

_________________________________________________________________________________

Principal Business of Enterprise/Corporation

1. Do any of your University activities sponsored by this enterprise involve technology developed at the University and which is now owned by or contractually obligated to this enterprise?

_____YES ______NO

If YES, respond to item #7.

Complete the following (2-4) if you answered YES to Questions 1,2,3 or 4 on the Annual Faculty Report Form.

2. Type of board, board committee, executive position, or other employed relationship held by you or your immediate family member.

3. Describe the responsibilities of this employed relationship.

4a. Describe the University activities funded by this enterprise/corporation in which you are a participant.

4b. Describe the invention and/or software which is licensed or the enterprise and how it relates to your work for the enterprise and for the University.

4c. Specify the type of funding, gifts, gratuities, consulting fees, royalties or other compensation (direct or deferred) received by you or your immediate family member (other than occasional meals, complementary copies of textbooks, etc.) from the enterprise or corporation during the last 12 months.

Complete the following if you answered YES to Questions 3 or 5 on the Annual Faculty Report Form.

5. If you answered YES to Q3, complete the following and respond to item #7.

a. Describe the nature of your financial interest in the enterprise or corporation.

b. If you have an ownership interest, is it less than $10,000 per annum of equity, salary, fees or other continuing payments or which represents 5% or less ownership interest for any one enterprise or entity when aggregated for the investigator and his/her immediate family. (See complete definition for significant financial interest , Section VIII., subsection 4.)

c. What is the duration of the sponsored research, outreach extension, testing or service?

6. If you answered YES to Q5, complete the following and respond to item #7.

a. Describe the University Position you hold in which you supervise, select or evaluate services provided to the University by the enterprise or corporation.

b. List the services involved.

c. Does the enterprise or corporation compete with services provided by the University?

______YES _____NO

If YES, describe these services.

7. Provide a discussion of the activities and actions or safeguards you will take to prevent your activities from affecting your objectivity as a University employee or will otherwise protect the University's interest, if you answered yes to Question 3, 5 or 6 on the annual report form.

SIGNATURES:

I certify that all of the above information is correct and that I will update this information promptly as changes occur.

______________________________________ __________________________________

Employee Signature Date

Reviewed by:

______________________________________ __________________________________

Department Head Dean