<!DOCTYPE HTML> <html><head><script src="/static/111213/js/perf/stub.js" type="text/javascript"></script><script src="/jslibrary/1725859384252/ui-sfdc-javascript-impl/SfdcCore.js" type="text/javascript"></script><script src="/static/111213/js/picklist4.js" type="text/javascript"></script><script src="/jslibrary/1698336664252/sfdc/VFState.js" type="text/javascript"></script><link class="user" href="/resource/1496706743000/YaleSitesCSS/PRO1.css" rel="stylesheet" type="text/css" /><link class="user" href="/resource/1496706743000/YaleSitesCSS/PROie9.css" rel="stylesheet" type="text/css" /><script src="/jslibrary/1698336664252/sfdc/NetworkTracking.js" type="text/javascript"></script><script>try{ NetworkTracking.init('/_ui/networks/tracking/NetworkTrackingServlet', 'network', '0664O000000uYBh'); }catch(x){}</script><script>(function(UITheme) { UITheme.getUITheme = function() { return UserContext.uiTheme; }; }(window.UITheme = window.UITheme || {}));</script></head><body>    <html dir="ltr" lang="en" version="HTML+RDFa 1.1" xmlns:content="http://purl.org/rss/1.0/modules/content/" xmlns:dc="http://purl.org/dc/terms/" xmlns:foaf="http://xmlns.com/foaf/0.1/" xmlns:og="http://ogp.me/ns#" xmlns:rdfs="http://www.w3.org/2000/01/rdf-schema#" xmlns:sioc="http://rdfs.org/sioc/ns#" xmlns:sioct="http://rdfs.org/sioc/types#" xmlns:skos="http://www.w3.org/2004/02/skos/core#" xmlns:xsd="http://www.w3.org/2001/XMLSchema#"> <head profile="http://www.w3.org/1999/xhtml/vocab"> <meta HTTP-EQUIV="PRAGMA" CONTENT="NO-CACHE" /> <meta HTTP-EQUIV="Expires" content="Mon, 01 Jan 1990 12:00:00 GMT" />  <style> body .secondaryPalette.bPageBlock { background-color: white; border: 0px; } body .bPageBlock .pbBody .labelCol { width: 30%; color: #585858; } body .bPageBlock .detailList tr th, body .bPageBlock .detailList tr td { border-bottom: 1px solid #add1eb; } body .bPageBlock .detailList table.multiSelectPicklistTable td { border: 0px; } .site-name-slogan { padding-bottom: 10px; } .fcoi_link_styleWh { font-size: 15px; padding-top: 8px; } .fcoi_link_styleWhLtBl { font-size: 15px; padding-top: 6px; padding-bottom: 4px; } tr:hover td { background-color: transparent; } </style> </head> <body class="html not-front not-logged-in page-node page-node- page-node-19 node-type-page context-contact-us one-sidebar sidebar-first accent-orange side-orange roman img-shadow"> <div id="skip-link"> <a class="element-invisible element-focusable" href="#main-content">Skip to main content</a> </div> <div class="region region-page-top" id="region-page-top"> <div class="region-inner region-page-top-inner"> </div> </div> <div class="page clearfix" id="page"> <header class="section section-header" id="section-header"> <div class="zone-wrapper zone-topper-wrapper clearfix" id="zone-topper-wrapper" style="background-color: #336699;"> <h2 class="fcoi_link_styleWh" style="padding-left:20px; "> <a href="http://www.yale.edu">Yale University</a> <div class="block-search-form "> <a href="https://your.yale.edu/">Portal</a>   |   <a href="http://calendar.yale.edu">Calendar</a>   |   <a href="https://www.yale.edu/directories" style="padding-right:20px;">A Z Search</a> </div> </h2> </div> <div class="zone-wrapper zone-topper-wrapper clearfix" id="zone-topper-wrapper" style="background-color: #678fba; border-top: 1px solid #ffffff;"> <h2 class="fcoi_link_styleWhLtBl" style="padding-left:20px; "> <a href="https://your.yale.edu/research-support/office-research-administration">OFFICE OF RESEARCH ADMINISTRATION</a> <div class="block-search-form"> <a href="http://www.yale.edu/fin-bus/">Finance & Business Operations</a>   |   <a href="https://provost.yale.edu/" style="padding-right:20px;">Office of the Provost</a> </div> </h2> </div> <div class="zone-wrapper zone-branding-wrapper clearfix" id="zone-branding-wrapper" style="background-color: #01346b; border-top: 1px solid #ffffff; padding-top: 6px;"> <h2 class="yale" style="padding-left:20px; "> <a href="https://your.yale.edu/research-support/conflict-interest-office">Conflict of Interest</a> </h2> </div> </header> <section class="section section-content" id="section-content"> <div class="region-inner region-content-inner"> <a id="main-content"></a> <input name="currentvfpage" type="hidden" value="FCOI_Request_Landing_Page" /> <form id="j_id0:PRO_SiteTemplate:page" name="j_id0:PRO_SiteTemplate:page" method="post" action="/FCOI_Request_Landing_Page" enctype="multipart/form-data" autocomplete="off"> <input type="hidden" name="j_id0:PRO_SiteTemplate:page" value="j_id0:PRO_SiteTemplate:page" /> <table width="100%"> <tr> <td style="background-color:#d4d4d4" width="1%"><br /> </td> <td style="background-color:#d4d4d4; border-right:thin solid black; font-size:11px" width="19%"> <br /><a href="https://your.yale.edu/research-support/conflict-interest-office"><b>Home</b></a> <br /><br /><a href="https://ires.yale.edu/WebPortal/Main.asp?Mode=COIUserSearch">External Interest Disclosure Form Login</a> <br /><br /><a href="https://your.yale.edu/research-support/conflict-interest/coi-policies-procedures">Policies & Procedures</a> <br /><br /><a href="https://your.yale.edu/research-support/conflict-interest/federal-and-other-coi-requirements-and-guidelines">Federal and COI Requirements & Guidelines</a> <br /><br /><a href="https://your.yale.edu/our-offices/research-support/ora-offices-and-staff/conflict-interest">Contact Us</a> <br /><br /> <br /><br /><br /><b>Relevant Offices</b> <br /><br /><a href="https://provost.yale.edu/">The Provost Office</a> <br /><br /><a href="https://your.yale.edu/research-support/office-research-administration">ORA: Office of Research Administration</a> <br /><br /><a href="https://your.yale.edu/research-support/human-research-protection-program">HRPP: Human Research Protection Program</a> <br /><br /><a href="https://your.yale.edu/research-support/office-sponsored-projects">OSP: Office of Sponsored Projects</a> <br /><br /> <br /><br /> <br /><br /> </td> <td style="font-size:12px; background-color:#ffffff" width="80%"> <br /> <h3>Financial Conflict of Interest (FCOI) Public Request Form</h3><br /> <p> Welcome to the FCOI Public Request Form. Please complete this form to request information on an FCOI identified on or after 8/24/12 related to Senior/Key investigators associated with a Public Health Service (PHS) funded award. If you need assistance in identifying the sponsor's award number and/or precise spelling of the Senior/Key investigator's name, please access the National Institutes of Health's RePORT tool for assistance at: </p> <a href="https://projectreporter.nih.gov/reporter.cfm">https://projectreporter.nih.gov/reporter.cfm</a>    or    <a href="http://report.nih.gov/index.aspx">http://report.nih.gov/index.aspx</a> <br /> <br /><p> Once you have submitted your request, you will receive a response within 5 business days. </p> <div style="width:100%; height:1px; background:#add1eb;"></div> <br /> <p><i> Please enter the information below. Required fields necessary to process your request are marked(*): </i></p><br /> <fieldset class="Application" style="float:left;"> <table> <tbody> <tr> <td style="font-size:10px; font-weight:bold; text-align:right;">Your Email Address*:</td> <td><input type="text" name="j_id0:PRO_SiteTemplate:page:j_id12" size="50" style="background-color:#B6C8DA; border:thin solid;" autocomplete="on" /> </td> </tr> <tr> <td style="font-size:10px; font-weight:bold; text-align:right;">PHS Project Title:</td> <td><input type="text" name="j_id0:PRO_SiteTemplate:page:j_id14" size="80" style="background-color:#B6C8DA; border:thin solid;" autocomplete="never" /> </td> </tr> <tr> <td style="font-size:10px; font-weight:bold; text-align:right;">PHS Award Number*:</td> <td><input type="text" name="j_id0:PRO_SiteTemplate:page:j_id16" size="50" style="background-color:#B6C8DA; border:thin solid;" autocomplete="never" /><br /><span style="font-style:italic">Format: 1R01CA012345-01</span> </td> </tr> <tr> <td style="font-size:10px; font-weight:bold; text-align:right;">Senior/Key Investigator's Last Name*</td> <td><input id="j_id0:PRO_SiteTemplate:page:formlnm" type="text" name="j_id0:PRO_SiteTemplate:page:formlnm" size="50" style="background-color:#B6C8DA; border:thin solid;" autocomplete="never" /> </td> </tr> <tr> <td style="font-size:10px; font-weight:bold; text-align:right;">Senior/Key Investigator's First Name:</td> <td><input id="j_id0:PRO_SiteTemplate:page:formfnm" type="text" name="j_id0:PRO_SiteTemplate:page:formfnm" size="50" style="background-color:#B6C8DA; border:thin solid;" autocomplete="never" /> </td> </tr> <tr> <td></td> <td><br /> <div align="left" draggable="false"> <script type="text/javascript" language="Javascript">function dpf(f) {var adp = f.adp;if (adp != null) {for (var i = 0;i < adp.length;i++) {adp[i].parentNode.removeChild(adp[i]);}}};function apf(f, pvp) {var adp = new Array();f.adp = adp;var ps = pvp.split(',');for (var i = 0,ii = 0;i < ps.length;i++,ii++) {var p = document.createElement("input");p.type = "hidden";p.name = ps[i];p.value = ps[i + 1];f.appendChild(p);adp[ii] = p;i += 1;}};function jsfcljs(f, pvp, t) {apf(f, pvp);var ft = f.target;if (t) {f.target = t;}f.submit();f.target = ft;dpf(f);};</script> <a href="#" style="left:0px;position:relative; font-size:12px;background:#00356b; color:white;text-decoration:none;padding:10px;float:center" onclick="if(typeof jsfcljs == 'function'){jsfcljs(document.getElementById('j_id0:PRO_SiteTemplate:page'),'j_id0:PRO_SiteTemplate:page:j_id22,j_id0:PRO_SiteTemplate:page:j_id22','');}return false" class="btn">Submit Request</a> </div> </td> </tr> </tbody> </table> </fieldset> </td> </tr> </table><div id="j_id0:PRO_SiteTemplate:page:j_id25"></div> </form><span id="ajax-view-state-page-container" style="display: none"><span id="ajax-view-state" style="display: none"><input type="hidden" id="com.salesforce.visualforce.ViewState" name="com.salesforce.visualforce.ViewState" value="i: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" /><input type="hidden" id="com.salesforce.visualforce.ViewStateVersion" name="com.salesforce.visualforce.ViewStateVersion" value="202411212046079980" /><input type="hidden" id="com.salesforce.visualforce.ViewStateMAC" name="com.salesforce.visualforce.ViewStateMAC" value="AGV5SnViMjVqWlNJNkluRnZXa1ZXTm1kb1VtMXpibk13WW1SbGIzWlpZM2hRVEVVeWFVaHhVbDlYZDBONU56WlFYMWxSYjFsY2RUQXdNMlFpTENKMGVYQWlPaUpLVjFRaUxDSmhiR2NpT2lKSVV6STFOaUlzSW10cFpDSTZJbnRjSW5SY0lqcGNJakF3UkZVd01EQXdNREF3U1djME5sd2lMRndpZGx3aU9sd2lNREpITUVJd01EQXdNREJaUXpaaFhDSXNYQ0poWENJNlhDSjJabk5wWjI1cGJtZHJaWGxjSWl4Y0luVmNJanBjSWpBd05UQkNNREF3TURBMlkwRk5PVndpZlNJc0ltTnlhWFFpT2xzaWFXRjBJbDBzSW1saGRDSTZNVGN6TWpNNE16UXpNekE0TVN3aVpYaHdJam93ZlE9PS4uT2NHLUZsN1pkLWxKMDlycDZXcEFrWXY4V2k1eDNHVWZOT3FhMTJMQ3llUT0=" /></span></span> <div class="block block-system block-main block-system-main odd block-without-title" id="block-system-main"> <div class="block-inner clearfix"> <div class="content clearfix"> <article about="/contact-us" class="node node-page node-published node-not-promoted node-not-sticky self-posted author-0 odd clearfix" id="node-page-19" typeof="foaf:Document"> <div class="clearfix"> <nav class="links node-links clearfix"></nav> </div> </article> </div> </div> </div> </div> </section> <footer class="section section-footer clearfix" id="section-footer" style="background-color: transparent; border-top: 1px solid #01346b;"> <div class="sharing"> <table> <tr class="zone-footer" style="hover:unset;"> <td class="region-inner region-footer-first" id="region-footer-first" style="padding-left:20px;" width="25%"> <h1 class="region-inner region-footer-first-inner"> <a href="http://www.yale.edu/">Yale University</a> </h1> </td> <td width="50%"> <div class="region-inner region-footer-second-inner"> <br /> <p class="copyright spacer" style="text-align:center;">Copyright © 2015 Yale University · All rights reserved · <a href="http://www.yale.edu/privacy.html" title="Yale Privacy policy">Privacy policy</a> <br /> <span class="spacer" style="text-align:center;">Contact us at <a href="mailto:conflicts@yale.edu">Conflict of Interest</a></span> </p> </div> </td> <td width="25%"> <ul class="menu"> <li class="last leaf menu-youtube" style="float:right; padding-left:20px; "> <a href="http://www.youtube.com/yale">YouTube</a> </li> <li class="leaf menu-itunes" style="float: right; padding-left:20px; "> <a href="http://itunes.yale.edu">iTunes</a> </li> <li class="leaf menu-flickr" style="float: right; padding-left:20px; "> <a href="http://www.flickr.com/photos/yaleuniversity">Flickr</a> </li> <li class="leaf menu-twitter" style="float: right; padding-left:20px; "> <a href="http://www.twitter.com/yale">Twitter</a> </li> <li class="first leaf menu-facebook" style="float: right; padding-left:20px; "> <a href="https://www.facebook.com/YaleUniversity">Facebook</a> </li> </ul> </td> </tr> </table> </div> </footer> </div> </body> </html><script type="text/javascript">Sfdc.onReady(function(){ SfdcApp && SfdcApp.Visualforce && SfdcApp.Visualforce.VSManager && SfdcApp.Visualforce.VSManager.vfPrepareForms(["j_id0:PRO_SiteTemplate:page"]); });</script></body></html>

CINXE.COM