<p> NON-FINANCIAL CONFLICT OF INTEREST STATEMENT FOR RESEARCH CONDUCTED AT THE VA PITTSBURGH HEALTHCARE SYSTEM ______</p><p>Instructions: The Non-Financial Conflict of Interest Statement must be completed by the Principal Investigator with each continuing review. Principal Investigators will be charged with answering the question below taking into consideration any real or perceived non-financial conflicts of interest they hold, as well as those held by any member of the study team.</p><p>PI Name: << Last Name>>, << First Name>>, <<MI>>, << Degree(s)>></p><p>Project Title: </p><p>MIRB # (if known): </p><p>To the best of your knowledge, do you or any member of YES, please provide details your research staff, have any potential, actual, or perceived below conflict of interest of a professional or personal nature that may affect any aspect of the research, including, but not NO limited to, the review and/or conduct of this research study?</p><p>Description, (including name of study team member with conflict): </p><p>In accordance with VAPHS Policy 008 (Non-Financial Conflict of Interest Policy)- Examples of such non-financial conflicts of interest may include: </p><p>(1) Personal Relationships (Relatives): A conflict of interest exists if a close relative is associated with the issue under review. For the purposes of this policy, a close relative is defined as a parent, spouse, sibling, son, or daughter, or domestic partner. (2) Personal Relationships (Friends): A conflict of interest exists if a close friend is associated with the issue under review. For the purposes of this policy, a close friend is defined as anyone giving or receiving a gift worth more than $50 in the last three years. Furthermore, anyone who considers him or herself a friend of any individual associated with the issue under review would also fall under this definition. (3) Professional Associates: Professional associate means any colleague with whom research is currently being conducted or with whom there are other significant professional activities. A conflict of interest exists if a professional associate is associated with the issue under review. A professional associate is also anyone who had a scientific mentor or mentee relationship within three years of the review of the issue. A conflict of interest also exists in any case wherein a professional associate is providing 30% or more effort (either in a single project or as a cumulative effort in other projects that may not be currently under review).</p><p>PI Signature: ______Date: ______</p><p>Version 1.0 10/30/2012 1</p>