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Financial Disclosure Form for Researchers

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Financial Conflict of Interest Disclosure Statement

This form is to be completed in connection with the Saint Luke’s Health System Policy on Financial Conflict of Interest in Research, ADM 015 by all key personnel who are involved in the review, design, analysis, conduct and/or reporting of research in which an entity of Saint Luke’s Health System is engaged or is reviewed by the Saint Luke’s Hospital Institutional Review Board. Answers should be completed based on the 12 months prior to form completion.

Should you have questions about the form, you may contact:

The Saint Luke’s Hospital Institutional Review Board, Central Office of Research Administration and Financial Conflict of Interest Committee will protect the confidentiality of private investments and personal finances and will request information related only to financial relationships that might influence the objectivity of research being conducted.

Your answer(s) to the questions do not imply that any financial interest you disclose is improper or impermissible. However, failure to report a financial interest or furnishing false, misleading or incomplete information may constitute professional misconduct and could be cause for disciplinary action.

You must fill out a separate form for each company in which you have a financial interest and update each form as changes occur.

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