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Request for Financial Conflict of Interest Information Under New Public Health Service Regulations

Under recent revisions to regulations which apply to investigators in receipt of research funding from the Public Health Service, Dartmouth College is required to make certain information about financial conflicts of interest held by its personnel available to the public.

 

Please use this form for all requests for information regarding financial conflicts of interest held by individuals who are subject to the Dartmouth College Conflict of Interest Policy.  You may either fill in this form and submit it via this website, or print this form and send it to the following address:

 

Conflict of Interest Officer
Office of the Vice Provost for Research
6004 Parkhurst Hall, Room 102
Dartmouth College
Hanover, NH 03755
ATTN: FCOI Information Requests

 

In response to a request for information submitted as described above, Dartmouth College will provide information to the requestor under the following conditions:

 

1. The subject of the request is an individual who is identified as senior/key personnel on a PHS-funded research project for which a Notice of Award was received on or after August 24, 2012.
2. A significant financial interest was disclosed to Dartmouth College by such individual and the individual still holds the significant financial interest.
3. The significant financial interest is related to the PHS-funded research.
4. The significant financial interest is a financial conflict of interest.

 

If the subject of the request meets the above criteria, Dartmouth College will issue a response to the request in writing within five (5) business days of the receipt of the request by the Conflict of Interest Officer.

 

Please submit a form for each investigator about which financial conflict of interest information is being requested.  More information about PHS-funded research projects can be found at http://report.nih.gov/.

Please provide the following information about the person making this request:

**A valid email or mailing address must be provided in order to receive a response to your request.

Your Name:

Address (street number, city, state, zip code):

Phone:

Email:

Please provide the following information about the subject of the request:

**You must provide sufficient information to identify the individual and the project that is the subject of your request.

Investigator Name:

Dartmouth Department:

Research Project Title:

PHS Award Number:

Please describe the reason that you are requesting this information:

Comments: