Thomas Jefferson University

Financial Conflict of Interest Information Disclosure Request

Research projects at Thomas Jefferson University and Jefferson Health (“Jefferson”) that are funded by an agency of the Public Health Service (PHS), such as the National Institutes of Health, must ensure public access to certain information about conflicts of interest that have been disclosed to Jefferson and reported to the funding agency. U.S. regulations allow anyone to request information about a conflict of interest held by senior or key personnel on a PHS-funded research project.

Public accessibility requests must be in writing by using the form below. Please provide as much information as possible about your request.

Jefferson’s Conflicts of Interest Committee will not assign a dollar range value to a Significant Financial Interest if it cannot readily determine its value through reference to public prices or other reasonable means to determine fair market value.

We will respond to requests via the manner you select on the form within five business days and will include information required to be disclosed by the U.S. Code of Federal Regulations.

For additional information or assistance with requesting financial conflict of interest information, contact 215-503-6300 or JeffCOISmart@Jefferson.edu.

1. Name of Requestor:*

2. Mailing Address & E-Mail Address : *

3. Preferred method of response transmission (Check one) *

 Electronic Mail
 First Class Mail

4. Name of Investigator about whom you are inquiring*:

5. Title of Investigator about whom you are inquiring:

6. Name and/or grant number of the NIH-funded research project about which you are inquiring, if available:

7. Purpose of the Inquiry:

8. Additional Comments: