Corporate Compliance

Medical College of Wisconsin Conflict of Interest Annual Certificate

This certificate applies to the academic year July 1, 2011 through June 30, 2012.  If you need additional space or to explain any "No" answers to statements 1 through 5 below, use the text box provided at the end of the form; upload a file at the end of the form; or send additional documentation interoffice to the MCW Corporate Compliance office as necessary.

Conflict of Interest, Outside Professional Activities and Consulting Policy (must be logged on to the MCW network to view)

(click on one answer to select)

1.  I certify that I have complied with the Policy by not participating in the following prohibited activities that constitute a conflict of interest:

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 a 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.

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 the text box at the end of the form if necessary; upload a file at the end of this form; or send additional documentation interoffice to the MCW Corporate Compliance office.

NOTE:  Please be detailed in your responses.  Answers such as "various", "pending", "unknown" or "to be determined" will not be accepted, and you will be asked to resubmit the form in its entirety.  Corporate Compliance verifies the information submitted with available industry reports.

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. 

Financial Conflict of Interest in Research Policy (must be logged on to the MCW network to view)

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):

5.  I certify that I comply with the MCW Financial Conflicts 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 interest) 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.

Financial Conflict of Interest in Research - Changes Coming

The Department of Health and Human Services issued a rule (DHHS 42 CFR 50 Subpart F) which amended the PHS regulations regarding Financial Conflicts of Interest in Research.  Organizations and their employees that receive PHS funds (including the NIH, CDC and HRSA) have until August 2012 to be in compliance.  These new regulations make several significant changes to the old rule including additional training, monitoring and reporting requirements.  Two changes in the regulation that immediately affect federally funded MCW research personnel are:

• DHHS has lowered the requirement for disclosure of financial interests from $10,000 to $5,000 during a 12 month period effective August 2012. You may be required to complete a separate disclosure form in August if your financial interests today are less than $10,000 but more than $5,000.

• Training for key personnel is required by the new rule.

More information on the new regulation can be found here:  http://grants.nih.gov/grants/policy/coi/coi_faqs.htm.  If you have further questions, please contact the Research Compliance Office: stoflet@mcw.edu

Health Care Industry Product Interactions Policy (must be logged on to the MCW network to view)

MCW Employees should be aware that the Health Care Industry Product Interactions Policy prohibits gifts from Industry to individuals including free drug samples, textbooks, equipment, travel costs, or monetary payment.

Required Explanation for "No" Answers or Any Other Additional Information:

Click "Browse" to Upload Additional Documentation Here:

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.

First Name:

Last Name:

E-Mail Address:

Employee ID Number:

If you do not know your Employee ID please click here to lookup your number (opens in new window)

NOTE:  In order to use this feature, you must be signed onto the MCW network.