Conflict of Interest

This questionnaire has been prepared to help us carry out the policy on Conflicts of Individual Interest in Research (“COIIR”) as promulgated by the Associate Vice President for Research on August 2002. The COIIR Committee has also determined that the questionnaire is necessary to comply with other federal regulations.

WHO MUST COMPLETE THE FORM

This form must be completed under the Policy for any persons Conducting Research on human subjects and for anyone whose research is covered by applicable federal regulations (42 C.F.R. §§50.603 and 50.604). This includes full time and part time salaried employees of Rush, anyone with a Rush faculty appointment or persons who use Rush facilities to support their research or clinical activities.

As defined in the Policy, "Conducting Research" means, with respect to a research protocol:

• designing research;
• directing research or serving as a principal investigator;
• enrolling research subjects (including obtaining subjects’ informed consent);
• making decisions related to eligibility to participate in research;
• analyzing or reporting research data; or
• submitting manuscripts concerning the research for publication.

The COIIR Committee has also determined that Rush must follow PHS research guidelines (42 C.F.R. §§50.603 and 50.604) for any persons conducting basic and applied research and product development using direct federal funds or federal funds subcontracted from any source and which relates broadly to public health including behavioral and social-sciences research.

By law and Rush policy, this form must be completed annually and in advance of any federal application for support.

Your responses should cover the period from January 1, 2004 to December 31, 2004.

In order to keep the form confidential, please return it by hand delivery or by interoffice mail to Matt Raymond, Rush Conflicts Officer, Suite 456 TOB. You may also e-mail a signed and scanned copy of the form to COI_Rush@Rush.edu