Financial Interest Disclosure

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iFoqq5bEWtDQvjuamgIYsxqquye6HNUMzeWttA2rV92fR9UMmCTswRt8FF8r7VmsgVgrtSJNMAGfmCWimxwcR5sVzVpTNxESgwJ7H

Financial Interest Disclosure

Because you are involved in a research project that is being conducted or being proposed to be conducted at or funded through MaineHealth, or conducted under the auspices of MaineHealth, you are required to complete the financial of interest disclosure below.

Please be certain to answer ALL of the questions. The IRB will be unable to review the project until the disclosure is completed.

For questions, please contact the Office of Research Ethics and Compliance at mmc_irb@mainehealth.org.

First name
Middle initial

* must provide value

Last name

* must provide value

Email address

* must provide value

1. Supervisor / Chief

* must provide value

2. Who is your employer?

* must provide value

Franklin Memorial Hospital

LincolnHealth - Boothbay Harbor

LincolnHealth - Damariscotta

Maine Behavioral Healthcare

Maine Medical Center

Mid Coast - Parkview

Pen Bay Medical Center

Southern Maine Health Care - Biddeford

Southern Maine Health Care - Sanford

Spring Harbor Hospital

Stephens Memorial Hospital / Western Maine Health

Waldo County General Hospital - Belfast

Other or outside collaborator or subcontractor (Specify below)

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2a. Outside collaborator or subcontractor, specify:
(If non-MaineHealth, please name the MaineHealth person and or project you are completing this financial COI disclosure for)

* must provide value

3. I have the following roles (Choose all that apply)

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Physician

Advance Practice Professional

Pharmacist

Supply Chain Buyer

Faculty

Scientist/Investigator

Research Staff

MMC/MMP Manager or Director

MMC/MMP Chief, VP or Senior Leader

MaineHealth Corporate Manager and Above

Other (specify)

3a. If other, please specify.

* must provide value

4. I serve on the following MaineHealth Entity Board(s) or Committee(s) (Choose all that apply)

* must provide value

Pharmacy and Therapeutic Committee - P&T

Value Analysis Committee - VAC

Institutional Review Board - IRB

Clinical Technology and Information Committee -CTIC

Research Conflict of Interest Committee - RCOI

Institutional Animal Care and Use Committee - IACUC

MaineHealth Pharmacy Directors

MaineHealth Imaging Leadership

MaineHealth Supply Chain Steering Committee

Technology Review Committee (TRC)

Not applicable

5. Do you identify as having a primary affiliation with any of the following Programs/Departments?

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Adult In-patient Medicine (AIM) Service Line

Cardiovascular Service Line

Oncology Service Line

Neurosciences Service Line

Surgery Service Line

Woman and Infants Service Line

Patient Care Services

Medical and Academic Affairs

Pediatrics

ED and Urgent Care

Primary Care

Orthopedics

Other (specify below)

Not applicable

Specify other primary affiliation below

6. Check one of the boxes below that applied to you, or any immediate family member in the last 12 months or since your last disclosure, if applicable:

(For the items below, do not consider mutual funds or retirement accounts)

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6a. I, or any immediate family member, have no financial interests (income, stock or equity) valued over $5,000 with a commercial entity producing health care related products and/or services; or

6b. I, or any immediate family member, have a financial interest (income, stock or equity) valued over $5,000 with a commercial entity that does not produce health care related products and/or services relevant to my position or research activities (for example, I own and have direct control over stock in the medical device manufacturer Smith worth about $10,000, but I do not use any Smith products in my work at MMC.); or

6c. I, or any immediate family member, have a financial interest (income, stock or equity) valued over $5,000 with a commercial entity that produces health care related products and/or services relevant to my position or research activity (for example, I have a consulting contract with pharmaceutical company Jones from which I am compensated more than $5000 in a calendar year, and I also prescribe Jones's drugs for my patients at MMC. I own and have direct control over stock in the pharmaceutical company Jones worth about $6,000 and I am a member of the Pharmacy and Therapeutics committee that considers Jones's drugs for the MMC formulary. I own and have direct control over stock in the medical device manufacturer Smith worth about $10,000 and I am involved in a clinical trial for an orthopedic device manufactured by Smith)

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If you checked 6c - Please disclose any financial interests valued over $5,000 in commercial entities that produce health care related products and/or services relevant to your position or research activity:

* must provide value

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7. Intellectual Property Relating to Health Care (including patents, copyrights, and trademarks): In the last 12 months, did you or an immediate family member have rights to, or receive royalties from intellectual property relating to health care? This includes intellectual property owned or licensed to an outside entity. It also includes acting as a principal (e.g., officer, board member) in a company that owned or licensed intellectual property relating to health care.

* must provide value

Yes No

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7a. If yes, for each, please list
(a) who owns the IP
(b) the name of the outside entity
(c) description of the agreement

* must provide value

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8. Uncompensated Outside Activities: In the last 12 months or since your last disclosure, did you or an immediate family member hold any government office or participate in uncompensated outside activities (e.g., board membership) for an entity that does business with, or may be in competition with MaineHealth?

* must provide value

Yes No

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8a. If yes, please explain

* must provide value

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9. Health Care Vendor Gift Disclosure: Did you receive any gifts, including entertainment and/or hospitality (reimbursement for travel, lodging and/or meals) from outside organizations that do business with MaineHealth?

Note that MMC and MMP employees may not accept gifts, hospitality or entertainment of any value from health care vendors. When approved by a supervisor and the Purchasing Department, a vendor may support travel to an external site, food and lodging for an MMC employee for the purposes of evaluating equipment that MMC is considering purchasing or for the purpose of training on equipment that MMC has purchased (where such training is included in the sales agreement). Other company supported travel is prohibited for MMC employees.

* must provide value

Yes No

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9a. If yes, please describe the gift and estimate its value:

* must provide value

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10. Are you currently receiving or seeking any research-related federal funding?

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Yes No

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11. Do you or an immediate family member have any equity interest in a non-publicly traded company (such as stock, stock options, or other ownership interest) that produces health-care related products or services?

* must provide value

Yes No

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11a. If yes, identify the company, nature of ownership, and specific dollar amount

* must provide value

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12. Have you or an immediate family member been reimbursed for any travel by a U.S. for-profit company or any foreign entity (for profit or non-profit)?

* must provide value

Yes No

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12a. If yes, identify company and amount or nature of reimbursement or payment

* must provide value

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13. For All Researchers, Scientists and Principal Investigators:
I attest that I have reviewed the Policy MaineHealth Research FCOI (Policy link available below) and the FCOI Web-Based NIH Tutorial (see link below)

* must provide value

Yes N/A

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Policy on the Conflict of Interest in Research

Also, please click FCOI Web-Based NIH tutorial to review the NIH FCOI Web-Based tutorial.

Attachment:

MaineHealth Research FCOI Policy Nov2020.pdf

14. For All MMC and MMP Employees:
I attest that I have reviewed the policy Promoting Healthy Partnerships with Health Care Vendors. and Maine Medical Center Conflict of Interest Policy (Policy links below)

* must provide value

Yes N/A

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Promoting Ethical Partnerships with Health Care Vendors

Attachment:

MMC Promoting Ethical Partnership 20190605.pdf

Maine Medical Center Conflict of Interest Policy

Attachment:

Maine Medical Center Conflict of Interest Policy 20190513.pdf

Date completed

M-D-Y

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