CONFLICT OF INTEREST DISCLOSURE
The primary goal of an annual conflict of interest disclosure is to manage potential and actual conflicts
of interest. When completing this form, if you are unsure whether or not to include information, please
include it. The information provided is maintained in a confidential manner by Mines, subject to the
procedures outlined in the Conflict of Interest Policy.
Complete all the information
Check all categories applicable to this submission
Change, Addition, or
Correction to Reporting
Check all categories that apply to you
Mines personnel responsible
for Conduct, Design or
Reporting on Research
Immediate Family – The immediate family member of a faculty member and includes the
faculty member’s spouse, domestic or civil union partner and dependent children.
Institutional Responsibilities - Institutional Responsibilities are the faculty member’s professional
responsibilities on behalf of CSM, and typically refers to the performance of duties related to research,
scholarship, education and service. Examples may include, but not be limited to, activities such as
research, research consultation, teaching, work on scholarly publications, and service on institutional
Equity refers to an interest or stake in an entity including, but not limited to: stock, stock options,
warrants, or any security representing ownership/stake in an entity.
or No, or
YES 1. During the past 12 months, I (and/or my Immediate Family) received compensation
and/or payments for services (Remuneration) (e.g., consulting fees, honoraria,
income from external business/employment) that when aggregated, exceeds $5,000
in value from an external organization or activity that has/had a relationship to my
(*Do NOT include any salary or remuneration received from Mines if you are currently employed
or appointed by Mines. Do Include outside business/employ in area of your Mines' employ.)
YES 2. During the past 12 months, I (and/or my Immediate Family) owned Equity interests,
such as stocks, stock options, or other ownership interests either in
a) publicly traded corporations that when aggregated exceed either $5,000 in
value or 5% ownership interests in any single entity;
b) privately-held entity that has any dollar value/level of ownership and has/had a
relationship to my Institutional Responsibilities.
(**Do NOT include any Equity interest in mutual or pooled funds that you or your Immediate
Family does not have direct control over. e.g. PERA, 401k or 403b where you do not select
the specific companies or stock, etc.)
YES 3. I (and/or my Immediate Family) am an inventor of intel ectual property, outside of my
Mines employment, that has been or will be licensed by an external organization to
a) have received/will receive financial consideration, (e.g., license fees, royalties
b) created, discovered, and/or reduced to practice an invention(s) using ***Mines’
resources for which title has not been assigned to Mines.
(***Do NOT include any payments (e.g. royalties, etc.) you are receiving from Mines for
Mines-owned intellectual property.
“Mines resources” may include, but are not limited to: office/lab space; computers;
equipment; funding; grant funds; time; personnel; etc.)
YES 4. During the past 12 months, I was directly reimbursed for travel or was provided travel
by an ****external organization (non-governmental)/party and this travel was
related to my Institutional Responsibilities.
(****Do NOT include travel reimbursed/flowed through the Mines’ payment system nor
travel reimbursed or sponsored by a federal, state, or local government agency, an
institution of higher education, an academic teaching hospital, a medical center, or
research institute that is affiliated with an institution of higher education.)
YES 5. During the past 12 months, I (and/or my Immediate Family Member) served on a
board of directors, advisory board, and/or as an officer of an organization doing
Business with Mines. *****Business may include sponsored or non-sponsored research,
selling a product to Mines, or providing services, etc.
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or No, or
YES 6. In the next 12 months, I anticipate change(s) to at least one item that I reported
in items 1 through 5 above. If yes, please explain below:
If you answered YES to one or more of the above questions, you must provide additional
information in the Conflict of Interest Disclosure Supplement.
By my signature below, I am acknowledging and agreeing to the fol owing:
• I have read and understand the Colorado School of Mines Faculty Handbook and Conflict of
Interest Policy, located in the Mines Policy Library and I am completing and filing this form in
accordance with Mines’ Policy;
• I understand that I have a continuing obligation to update and revise my disclosure form no
later than 30 calendar days after discovering or acquiring (e.g., through purchase, marriage,
inheritance or otherwise) any change in my and/or my Immediate Family’s outside activities or
related financial interests during the course of the next reporting period; AND
• I understand that annual conflict of interest disclosures are required as part of and a condition
to my employment with the Colorado School of Mines.
By my signature below, I certify to the best of my knowledge that the information I
have provided on this Conflict of Interest Disclosure and the Disclosure Supplement
hereto is true and complete, and that I am in compliance with the Colorado School of
Mines Conflict of Interest Policy.
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CONFLICT OF INTEREST DISCLOSURE SUPPLEMENT
For any areas that you checked YES on the COI Disclosure, please provide additional
information in the appropriate chart.
Total $ received
Description of Services
in the last 12
months from each
Name of Entity
Market Value ownership
e[change" warrants, etc. of Shares ($)
Receiver of IP
Subject Matter of IP
the last 12
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(e.g., Scientific meeting, research
(Name, relationship Date of
development, data collection)
(Name, relationship to
(total days in the past 12
**If additional pages are necessary you may add them as needed.
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