Faculty/Staff Disclosure

SAM HOUSTON STATE UNIVERSITY
FACULTY/STAFF DISCLOSURE STATEMENT

NAME/TITLE	________________________________________
COLLEGE/DEPARTMENT	________________________________________
TITLE OF SPONSORED PROJECT	________________________________________
PROJECT PERIOD	________________________________________

CERTIFICATION:	I have read and concur with the Sam Houston State University Conflict of Interest Policy

Are you or any member of your immediate family (spouse, parents, parents-in-law, siblings, children, or other relatives living at the same address as faculty member) an officer, director, partner, trustee, employee, advisory board member, or agent of the external organization funding this sponsored project or of any organization from which goods and services will be obtained under the sponsored project?

________	yes	(if so, describe in detail the nature and extent of the affiliation on an
		attached sheet).
________	no

Are you or any immediate family member the actual or beneficial owner of more than five percent (5%) or $10,000 of the voting stock or controlling interest of the external organization funding this sponsored project or any external organization from which goods and services will be obtained under this sponsored project?

________	yes	(if so, describe in detail the nature and extent of the equity interest on an
		attached sheet).
________	no

Have you or any member of your immediate family derived income within the past year or do you or any member of your immediate family anticipate deriving income exceeding $10,000 per year from the external organization funding this sponsored project or any external organization from which goods and services will be obtained under this sponsored project?

________	yes	(if so, describe on an attached page the amount of the income and the reason
		for which it was or will be derived).
________	no

Do you have any affiliation with the external organization that would diminish your ability to fulfill your paramount obligations to your students, your colleagues, or the university; or have you involved any graduate student in a proprietary capacity with the external organization?

________	yes	(if so, describe on an attached page the nature of the affiliation and the
		amount of time per week you dedicate to it).
________	no

Signature of Faculty/Staff Member

______________________________________________

Date__________________________________________

Signature of Department Chair (or immediate supervisor)

______________________________________________

Date__________________________________________

Signature of Academic Dean (for faculty only)

______________________________________________

Date__________________________________________

Administrative Review and Approval

1. Based on the activity reported, to the best of my knowledge and in my judgment:

________	a.	No real or potential conflict of interest exists.
________	b.	A real or potential conflict of interest may exist which warrants further
		review. (Attach an explanation).


________________________________		Date______________________________
Associate Vice President Research and Sponsored Programs

Academic Policy Statement 950809
Attachment A: Appendix