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Yes
No
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1. I certify that I have complied with the Policy by not participating in the following prohibited activities
that constitute a conflict of interest:
• Using the employee's position to gain anything for the private benefit of the employee.
• Soliciting anything of value from a third party with the express or implied understanding that the employee's conduct of business would be influenced thereby.
• Disclosing MCW confidential information in return for the receipt of anything of value for the employee.
• Entering into a contract or lease where the employee can approve or influence the decision to enter into the lease.
• Engage in the private practice of medicine, whether or not on vacation time, if a full-time or full professional effort faculty member.
• Testify as an expert witness against MCW or MCW personnel acting in their official capacities.
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Yes
No
No Activities To Report
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2. I certify that I have obtained MCW approval prior to participating in the following activities that may
create a conflict of interest:
• Entering into a contract or lease between MCW and the employee, or an immediate family member, or an organization with which the employee is associated, regardless of whether the employee can influence the decision.
• Acceptance of a grant or contract for conduct of research which uses MCW personnel or property, except under an agreement approved by the Grants and Contracts Office.
• Regular teaching at another educational institution.
• De facto employment (providing services on demand) for an outside employer.
• Lending an employee's name or professional endorsement to a product.
• The transfer by any full-time or full professional effort faculty member of any proprietary rights, such as a copyright or patent, to any organization other than the MCW Research Foundation.
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Yes
No Activities to Report
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3. I have participated in outside professional activities such as consulting or serving as an expert witness
or officer or board member of a health care organization.
- If you answered "Yes" to questions 2 or 3 complete the following section. Please use text box at the end of the form if necessary.
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Yes
No
Not
Applicable
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4. For full time and full professional effort faculty and staff physicians: For the indicated academic year,
all my patient-care related fees (as defined in the Faculty Practice Plan, p.11) have been billed through
Medical College Physicians, Children's Specialty Group or through Medical College of Wisconsin Service
Contracts.
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Financial Conflict of Interest in Research Policy
For all investigators conducting research, individuals planning to participate in research and any other person responsible for the design, conduct or reporting of funded research (key personnel):
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Yes
No
Not
Applicable
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5. I certify that I comply with the MCW Financial Conflict of Interest in Research Policy regarding whether I
(and spouse or domestic partner and dependent children) have any known Significant Financial Interests
(as defined below) in entities that may potentially benefit in new or promising ideas, products, or
technologies related to my research activities.
Significant Financial Interests are defined as anything of monetary value, including but not limited to,
salary or other payments for services (e.g. consulting fees or honoraria), equity interest (e.g. stocks,
stock options or other ownership interests) or intellectual property rights. Equity interests become
"significant" if, for any one enterprise, the interests have a value of $10,000 or more or represent more
than 5% ownership interest. Note that this threshold applies to the individual or aggregated interest of
the investigator (or other key personnel), spouse or domestic partner, and dependent children.
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Health Care Industry Product Interactions Policy
MCW Employees should be aware that the Health Care Industry Product Interactions Policy was approved by the Board of Trustees effective March 1, 2009 and requires concurrent or prospective reporting of participation in Industry sponsored events or interactions. Furthermore, this policy prohibits gifts from Industry to individuals including free drug samples, textbooks, equipment, travel costs, or monetary pament. The policy and additional information can be found at the following link: http://infoscope.mcw.edu/ConflictofInterestandCommitment.htm.
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Required Explanation for "No" Answers and Any Other Additional Information:
I certify that I have read and understand the College's Policies on Conflicts of Interest, Outside Professional Activities and Consulting, and Financial Conflicts of Interest in Research. I will promptly report to my Department Chair, the Dean, Senior Associate Dean for Research and/or the Senior Vice President any situation that raises an issue of a conflict of interest or the appearance of a conflict of interest with my duties to the College.
By submitting this form, I certify I am the individual who completed this form. I certify that to the best of my knowledge, I have truthfully and accurately completed the annual certificate.
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