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Protocol-Related Conflict of Interest Form

Members of the SIU SOM research community need to be conscious of potential impacts of financial interests and/or non-financial relationships with commercial sponsors or other external entities when conducting research.  To remain in compliance with federal regulations and SIU SOM policy, SCRIHS considers such relationships when conducting the review of human subject research submissions. The Protocol-Related Conflict of Itnterest Form should be completed and included with the initial and continuing review submissions of research studies that are industry sponsored.  The completed form should include all study personnel. 


Relationships to be disclosed include, but are not limited to:

  • Compensation (bonus, royalty, or other financial incentive) made to the investigator/study personnel whereby the outcome of the study could affect investigator/study personnel compensation (e.g., compensation would be higher for a favorable outcome).

  • Significant payments to the investigator/study personnel or institution with a monetary value greater than $5,000 (e.g., grants, equipment, retainers for ongoing consultation, or honoraria) over the cost of conducting the trial*. Any such payments to the investigator/study personnel or institution during the time the investigator/study personnel is conducting the study, and for one year following study completion, must be reported.

  • Investigator meetings required for participation in this study do not have to be disclosed to SCRIHS.

  • Proprietary interest in the test article (e.g., drug, device, technology), such as a patent, trademark, copyright or licensing agreement.

  • Significant equity interest in the sponsor such as ownership, interest, stock options, or other financial interests (during the time of conducting study and for one year following completion of the study), specifically:

    • any interest if the sponsoring company is privately held

    • any value greater than $5,000 if the sponsoring company is publicly held

Detailed information about the SCRIHS Conflict of Interest Policy can be reviewed in the SCRIHS Policies and Procedures Manual under the Conflict of Interest ("COI Policy") heading.  Please contact SCRIHS staff If you are unsure if the Protocol-Related Conflict of Interest form should be included with your submission.