<p> OFFICE OF ETHICS & COMPLIANCE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO</p><p>UCSF Conflict of Interest Advisory Committee</p><p>PRINCIPAL INVESTIGATOR CERTIFICATION FORM --- NON-PHS FUNDED RESEARCH</p><p>Principal investigators (PIs) and project directors (PDs) are required to sign this form for proposals to be submitted to the types of sponsors listed below, including all federal agencies, and must include the form with proposal documentation submitted to the Office of Sponsored Research. Principal Investigators (“PI”), co-principal investigators, and other individuals (e.g., postdocs) at UCSF who have responsibility for the design, conduct, or reporting of a project (“Investigators”) must disclose their financial interests in any organization that might benefit from the proposed research. Disclosure is required at the time a proposal is submitted to the sponsor and whenever there is a change in the financial interests of the Investigator(s). Additional information on the disclosure of financial interests related to sponsored projects is located at http://or.ucsf.edu/osr/coi.html. </p><p>Key personnel lists in order to complete financial interest reviews may not be required for these sponsors. </p><p>SPONSOR TYPE (please check one): CA Institute of Regenerative Medicine (CIRM) NASA</p><p>Department of Defense (DoD) UC Special Programs (AIDS, Tobacco, Breast)</p><p>National Science Foundation (NSF) Other </p><p>TITLE OF PROPOSAL: </p><p>UCSF Proposal Number: </p><p>This section must be completed by the Principal Investigator. The PI certifies on behalf of self, spouse, registered domestic partner, and dependent children, as well as on behalf of all investigators and their spouses, registered domestic partners, and dependent children. “Investigator” means anyone with responsibility for the design, conduct, or reporting of the research.</p><p>PRINCIPAL INVESTIGATOR Do you, your spouse, or dependent children have any direct, indirect, or related financial interest(s) related to the work to be conducted as part of this proposed project? Interests are related to the research if those interests: * could be affected by the results or outcome of the research, * are in the sponsor of the research (even if unrelated to the research being proposed), or * are in another entity conducting research or business that could be affected by the research. No Yes – Please identify investigator and describe conflict on separate page.</p><p>INVESTIGATORS (those others who have responsibility for design, conduct, or reporting of the research) Do any other UCSF Investigators, their spouses, or dependent children have any direct, indirect, or related financial interest(s) related to the work to be conducted as part of this proposed project? Interests are related to the research if those interests: * could be affected by the results or outcome of the research, * are in the sponsor of the research (even if unrelated to the research being proposed), or * are in another entity conducting research or business that could be affected by the research. No Yes - Please identify investigator and describe conflict on separate page.</p><p>PRINCIPAL INVESTIGATOR CERTIFICATION: I certify that the information provided above is accurate.</p><p>Name of Principal Investigator Signature of Principal Investigator (digital ok) Date</p><p>COIAC Office 4/17/2013 OFFICE OF ETHICS & COMPLIANCE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO</p><p>COIAC Office 4/17/2013</p>