EXPANDED CONFLICTS OF INTERESTS DISCLOSURE FORM UNIVERSITY OF OKLAHOMA HEALTH SCIENCES CENTER This form must be completed if the Principal Investigator/Employee answered YES to any questions on Part II of the Conflicts of Interest Disclosure Form or as otherwise required by the Conflicts of Interest Policy See: http://www.ouhsc.edu/Provost/FacultyHandbook/PDF/FacHandbookAppenE.pdf PERSONAL IDENTIFICATION Name College E-mail Title Department/Section Phone TYPE(S) OF DISCLOSURE (CHECK ALL THAT APPLY) New sponsored activity (research, training, or public service) New professional service (PPP) activity (consulting, speaking, training, etc.) Additional activity/relationship with a Sponsor/Company New Conflict of Interest relating to a previously disclosed activity Date of previous disclosure: Other: SPONSOR/COMPANY INFORMATION (if applicable) Type: Federal Sponsor/Company is: State Industry Privately Held Publicly Traded Non-Profit n/a Government Other Name and address of Sponsor/Company: ACTIVITY/RELATIONSHIP INFORMATION Type of activity/relationship: Consulting Gift Operating Officer Speaker Training Board Member Grant Research Director MTA Scientific Officer Other Title of this activity/relationship, if applicable: Description of this activity/relationship: Are students and/or post-doctoral fellows involved in the activity/relationship? Yes No If yes, describe the role they will play and any possible limitations on their ability to publish and/or progress in their program The signature of the Dean of the Graduate College must be obtained if students and/or post-doctoral fellows are involved