PHS Financial Conflict of Interest Information Request

The University of Illinois Policy on Financial Conflicts of Interest in Research (FCOIR) and federal regulations (42 CFR §50.605) require the University of Illinois Chicago (UIC) to provide, upon written request, certain information (see 42 CFR §50.605(a)(5)(ii)). This form is to be used for all requests for information regarding the financial conflicts of interest of senior and key personnel participating in research to meet these requirements.

Please complete one form for each individual investigator regarding whom information is requested. All information is required, unless marked as optional. If any information is not provided, the request may not receive a response.

Requester

Your Name(Required)
Given (First) Name Family (Last) Name
Your Address (Street, City, State Zip+4)(Required)
Your Email(Required)
Your Phone(Required)
(###) ###-###
UIC Investigator(Required)
UIC PHS Project(Required)
e.g., R## NS######, U## OH######,
Comments

Office of the Vice Chancellor for Research

PHS Financial Conflict of Interest Information Request