First Name
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Last Name
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KI E-mail
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an initial disclosure an annual disclosure an addendum to my most recent disclosure an addendum for travel purposes only to my most recent disclosure
Purpose
The form you are about to complete was designed to meet the disclosure requirements mandated by the Federal Public Health Service (PHS) regulations (42 CFR Part 50 and 45 CFR Part 94 ) on Promoting Objectivity in Research. This disclosure should include any significant financial interests related to your institutional responsibilities at Karolinska Institutet. Please consult the KI FCOI policy .
Definitions
EntityAny non-Karolinska Institutet, domestic or foreign, public or private, organization (excluding a Swedish or U.S. federal agency) from which you or your spouse or dependent children receive remuneration or have an ownership or equity interest.
EquityAny stock, stock option, or other ownership interest, whether or not the value can be determined through reference to public prices or other reasonable measures of fair market value.
RemunerationAny payment received from an outside entity in any form, including, but not limited to, stocks, bonds, stock options, warrants, partnership interests, rights to patent or royalty payments, consulting fees, honoraria, speaking fees, salary, loans, lectureship fees, or fees for serving on boards of directors, scientific and other advisory boards.
Significant Financial Interest- income exceeding $5,000 past 12 months - as of the date of disclosure, any combination of income and equity in a publicly traded company exceeding $5,000 - any equity interest in a non-publicly traded company - for you only: Third-party reimbursed or sponsored travel in any amount for any travel related to your organizational responsibilities for Karolinska Institutet - income exceeding $5,000 for intellectual property not owned by Karolinska Institutet
Non-reportable Interests include- financial interests or activities that do not relate to your academic or professional work at Karolinska Institutet - salary support received through Karolinska Institutet or salary support through Karolinska Institutet administered sponsored awards; - income from investment vehicles, such as mutual funds and retirement accounts, as long as you do not directly control the investment decisions made in these vehicles - travel expenses paid by Karolinska Institutet or by a sponsored research award to Karolinska Institutet - income from seminars, lectures, and teaching engagements sponsored by Swedish or U.S. federal, state, local, or other national government agencies; institutions of higher education or research institutes; academic teaching hospitals or medical centers that are affiliated with institutions of higher education - income from service on advisory committees or review panels for Swedish or U.S. federal, state, local, or other national government agencies; institutions of higher education or research institutes; academic teaching hospitals or medical centers that are affiliated with institutions of higher education - compensated activities and income derived from Swedish or U.S. government or non-profit research entities
Instructions
According to PHS regulations, a significant financial interest exists if the value of any remuneration received from any publicly traded entity in the twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of disclosure, when aggregated, exceeds $5,000.
Remuneration refers to salary as well as any other payments for services that are not explicitly classified as salary. (e.g., consulting fees, honoraria, paid authorship).
Equity interest includes any stock, stock option, or other ownership interest, as determined through reference to public prices or other reasonable measures of fair market value.
Because PHS regulations do not exclude income from authorship activities, you must include them in your response to the following question.
Receiver: the individual who received the remuneration (you, your spouse, your dependent children)
Equity holder: the individual who holds the equity (you, your spouse, your dependent children)
Please do not include equity, royalties, or other payments on intellectual property rights in your response to this question.
1. (a) In the past 12 months, did you, or your spouse, or your dependent children receive any remuneration (e.g. consulting fees, honoraria, speaker fees, or advisory board fees) from any publicly traded entity that, when aggregated exceeds $5,000?
* must provide value
Yes No
Please disclose additional remuneration information for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Publicly Traded Entity no1 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a second publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Publicly Traded Entity no2 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a third publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Publicly Traded Entity no3 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a fourth publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Publicly Traded Entity no4 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a fifth publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single publicly traded entity in the table below. If you need to provide additional information kindly contact the sender of this survey.
Remuneration from Publicly Traded Entity no5 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
1. (b) As of the date of this disclosure, do you, or your spouse, or your dependent children hold any equity interests in a publicly traded entity? If so, does the value of this equity exceed $5,000 either on its own or when aggregated with any other remuneration from the same entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Publicly Traded Entity no1 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interest in a second Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Publicly Traded Entity no2 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a third Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Publicly Traded Entity no3 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a fourth Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Publicly Traded Entity no4 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a fifth Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single publicly traded entity in the table below. If you need to provide additional information kindly contact the sender of this survey.
Equity Interests in a Publicly Traded Entity no5 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Instructions
According to PHS regulations, a significant financial interest exists if the value of any remuneration received from any non-publicly traded entity in the twelve months preceding the disclosure, when aggregated, exceeds $5,000 when you (or your spouse or dependent children) holds any equity interest in the same entity.
Remuneration includes salary and any payment for services not otherwise identified as salary (e.g., consulting fees, honoraria, paid authorship).
Equity interests include stock, stock options, or other ownership interests.
Because PHS regulations do not exclude income from authorship activities, you must include them in your response to this question.
Receiver: the individual who received the remuneration (you, your spouse, your dependent children)
Equity holder: the individual who holds the equity (you, your spouse, your dependent children)
Please do not include royalties or other payments on intellectual property rights in your response to this question.
2. (a) In the past 12 months, did you, your spouse or your dependent children receive remuneration (e.g., consulting fees, honoraria, paid authorship) from any non-publicly traded entity that, in total exceeded $5,000?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Publicly Traded Entity no1 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a second non-publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Publicly Traded Entity no2 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a third non-publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Publicly Traded Entity no3 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a fourth non-publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Publicly Traded Entity no4 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
Do you have to declare remuneration from a fifth non-publicly traded entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-publicly traded entity in the table below. If you need to provide additional information kindly contact the sender of this survey.
Remuneration from Non-Publicly Traded Entity no5 Name of Entity: Type of Business: Amount in USD: Activity: Receiver:
2. (b) In the past 12 months, did you, your spouse or your dependent children hold any equity interests in any non-publicly traded entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Non-Publicly Traded Entity no1 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a second Non-Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Non-Publicly Traded Entity no2 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a third Non-Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Non-Publicly Traded Entity no3 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a fourth Non-Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single non-publicly traded entity in the table below. You will be able to provide information for additional entities in the next section further below.
Equity Interests in a Non-Publicly Traded Entity no4 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Do you have to declare entity interests in a fifth Non-Publicly Traded Entity?
* must provide value
Yes No
Please disclose additional information for equity interests for a single non-publicly traded entity in the table below. If you need to provide additional information kindly contact the sender of this survey.
Equity Interests in a Non-Publicly Traded Entity no5 Name of Entity: Type of Business: Type of Equity: Value in USD: Equity holder:
Instructions
Because PHS regulations do not exclude income for authorship activities or income from external professional organizations, you must include them in your response to this question. Also by PHS regulations, you must include income from a foreign institution of higher education or the government of another country in your response to this question.
Do not include the following- income from seminars, lectures, and teaching engagements sponsored by Swedish or U.S. federal, state, local, or other national government, institutions of higher education or research institutes, academic teaching hospitals, or medical centers that are affiliated with institutions of higher education - income from service on advisory committees or review panels for Swedish or U.S. federal, state, local, or other national government agencies, institutions of higher education or research institutes, academic teaching hospitals and medical centers that are affiliated with institutions of higher education, and - royalties or other payments on intellectual property rights in your response to this question.
3. In the past 12 months, did you, or your spouse or your dependent children receive any remuneration from a non-profit entity that when aggregated exceeds $5,000?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-profit entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Profit Entity no1 Name of Entity: Amount USD: Activity: Receiver:
Do you have to declare remuneration from a second non-profit entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-profit entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Profit Entity no2 Name of Entity: Amount USD: Activity: Receiver:
Do you have to declare remuneration from a third non-profit entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-profit entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Profit Entity no3 Name of Entity: Amount USD: Activity: Receiver:
Do you have to declare remuneration from a fourth non-profit entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-profit entity in the table below. You will be able to provide information for additional entities in the next section further below.
Remuneration from Non-Profit Entity no4 Name of Entity: Amount USD: Activity: Receiver:
Do you have to declare remuneration from a fifth non-profit entity?
* must provide value
Yes No
Please disclose additional remuneration information for a single non-profit entity in the table below. If you need to provide additional information kindly contact the sender of this survey.
Remuneration from Non-Profit Entity no5 Name of Entity: Amount USD: Activity: Receiver:
Instructions
Travel costs include meals, transportation, lodging, and registration fees.
Third-party paid travel means: - third party directly pays in whole or in part for travel on your behalf - you pay for travel and a third party reimburses you in whole or in part - Karolinska Institutet pays in whole or in part for travel and the third party reimburses Karolinska Institutet
PHS regulations include travel paid by: - for-profit entities - non-profit entities including external professional organizations and societies - academic journals and publishing companies; and - any travel reimbursed or sponsored by a foreign institution of higher education or the government of another country.
PHS regulations exclude travel paid by: - subrecipient Organization - Swedish and U.S. federal, state, or local government agencies - institutions of higher education or research institutes and - academic teaching hospitals or medical centers that are affiliated with Institutions of higher education.
4. During the past 12 months, did you have a third party pay for your travel that is related to your responsibilities at Karolinska Institutet?
* must provide value
Yes No
Please disclose travel information for a single travel in the table below. You will be able to provide information for additional travel in the next section further below.
Travel information no1 Destination: Duration of trip: Value in USD: Purpose: Sponsor of the trip:
Do you have to declare a second travel?
* must provide value
Yes No
Please disclose travel information for a single travel in the table below. You will be able to provide information for additional travel in the next section further below.
Travel information no2 Destination: Duration of trip: Value in USD: Purpose: Sponsor of the trip:
Do you have to declare a third travel?
* must provide value
Yes No
Please disclose travel information for a single travel in the table below. If you need to provide additional information kindly contact the sender of this survey.
Travel information no3 Destination: Duration of trip: Value in USD: Purpose: Sponsor of the trip:
InstructionsDo not include payments from or intellectual property owned by Karolinska Institutet. If you receive royalties or other payments exceeding $5,000, please disclose the name of the entity providing the
5. In the past 12 months did you, your spouse, or your dependent children have any income exceeding $5,000 for intellectual property rights (e.g., patents, patent applications, license agreements, or copyrights) resulting from or related to your work at Karolinska Institutet?
* must provide value
Yes No
Please disclose information for a single intellectual property right in the table below. You will be able to provide information for additional intellectual property rights in the next section further below.
Intellectual property right no1 IP/ invention short description: Status (licensed/ patented/ pending): Name of the entity providing the payment:
Do you have to declare additional intellectual property rights?
* must provide value
Yes No
Please disclose information for a single intellectual property right in the table below. You will be able to provide information for additional intellectual property rights in the next section further below.
Intellectual property right no2 IP/ invention short description: Status (licensed/ patented/ pending): Name of the entity providing the payment:
Do you have to declare additional intellectual property rights?
* must provide value
Yes No
Please disclose information for a single intellectual property right in the table below. You will be able to provide information for additional intellectual property rights in the next section further below.
Intellectual property right no3 IP/ invention short description: Status (licensed/ patented/ pending): Name of the entity providing the payment:
Do you have to declare additional intellectual property rights?
* must provide value
Yes No
Please disclose information for a single intellectual property right in the table below. You will be able to provide information for additional intellectual property rights in the next section further below.
Intellectual property right no4 IP/ invention short description: Status (licensed/ patented/ pending): Name of the entity providing the payment:
Do you have to declare additional intellectual property rights?
* must provide value
Yes No
Please disclose information for a single intellectual property right in the table below. If you need to declare more intellectual property rights kindly contact the sender of this survey.
Intellectual property right no5 IP/ invention short description: Status (licensed/ patented/ pending): Name of the entity providing the payment:
Hereby I certify that I have read and understand Karolinska Institutet's Financial Interest Disclosure Policy, I have completed the Conflict of Interest Course (COI) provided by the CITI program , and have completed this Disclosure to the best of my knowledge and belief. Further, as someone who is identified as an investigator on a PHS proposal/award, subaward, or non-federal sponsor adopting the Public Health Services (PHS) regulations, I agree to comply with PHS regulatory requirements adopted as Karolinska Institutet's policy (dnr 1-600/2014) as well as acknowledge the following: - no later than at the time of proposal/application I will ensure that a current financial interest disclosure is on file - I will fulfill my disclosed responsibilities at least annually or within 30 days of discovering or acquiring (e.g., through purchase, marriage, or inheritance) a new SFI during the period of the award whichever comes first, including the occurrence of any reimbursed or sponsored travel which is paid on my behalf, related to my responsibilities at Karolinska Institutet - if I fail to report a new SFI within 30 days, I will willingly participate in the required retrospective review of my research to determine bias - with the decisions of the COI Committee/designated official reflected in a management plan, if one is issued; - if I am a PI, I will appropriately identify individuals (i.e.," investigators") if any, in my proposal, who are responsible for the conduct, design, or reporting of the research. I will take into consideration the role of the investigator, rather than their title and the degree of independence with which the investigator will work - if I am a PI, I will complete my progress report in a timely fashion to assist the PHS Grantee in its reporting requirements related to any identified and previously reported FCOIs - that Karolinska Institutet must comply with written requests for information regarding my reported FCOIs within 5 business days and will include: - my name - my title and role in the research project - the name of the entity in which the significant financial interest is held - the nature of the significant financial interest and - the approximate dollar value of the significant financial interest will be provided in the following dollar ranges: $0-$4,999;$5,000-$9,999; $5,000-$19,999; amounts between $20,000-$100,000 by increments of $20,000; amounts above $100,000 by increments of $50,000, or a statement that the interest is one whose value cannot be readily determined through reference to public prices or other reasonable measures of fair market value and
-that Karolinska Institutet may impose sanctions on me if I fail to comply with the PHS regulations and Karolinska Institutet's policy.
Today Y-M-D
Disclaimer
Each subrecipient is legally required to independently assess the adequacy of its COI form for purposes of compliance with legal requirements, including compliance with the PHS financial conflict of interest regulations, and with other federal, state, local, and organizational requirements. This model form is provided as a tool to assist in drafting the subrecipient's form. No representation is made that this model form complies with any organization's particular legal requirements. Before finalizing or implementing this Form, consult with appropriate legal counsel to determine its legal sufficiency.
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