Request for Exemption to the Institutional Conflict Of Interest Policy

Please complete the survey below, the information will be reviewed by the Institutional Conflict of Interest Review Committee and a correspondence will be sent once a decision has been made.

Please review the Institutional Conflict of Interest Policy here: 3007---institutional-conflict-of-interest.pdf prior to completing and submitting this form.

Thank you.

Name

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Email Address

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What is your role/position at the University of Colorado?

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Which of the following activities are you requesting the ICOI Committee to review:

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Compensation for services on an external for-profit governance, advisory, or scientific board

Compensation in the form of stock options

Personal investment in faculty start up company

Other

Provide details regarding the activity of "Compensation for services on an external for-profit governance, advisory or scientific board"

For example specific name of company, duration of involvement, amount of compensation, etc. :

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Please provide details regarding the activity of "Compensation in the form of stock options"

For example specific name of company, duration of involvement, amount of compensation, etc., please be as detailed as possible:

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Please provide details regarding the activity of "Personal investment in faculty start up company"

For example specific name of company, duration of involvement, amount of compensation, etc. , please provide as much detail as possible:

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Please provide details for "Other"

Please be as detailed as possible with your response:

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Please Upload Email Communication and Documented Approval of Supervisor here

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Please upload appropriate "Scope of Work" document if available.

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Institutional conflicts of interest arise when the campuses' financial interests or those of its senior officials might have, or appear to have, undue influence on decisions involving the University's primary interests. ICOIs can affect the core mission of the University and damage public trust.

The presumption is that these policies will apply unless an exemption is requested and approved by the ICOIC in accordance with its charter. However, it is important to note that compelling and extensive evidence will need to be provided that the exemption is in the interest of the university and its missions and not just the individual(s) seeking the exemption.

As outlined in the ICOI Policy (Section E) the presumption is that activities be limited unless there is compelling and extensive evidence that the exemption is in the interest of the university and its missions and not just the individual(s) seeking the exemption.. Please list how this agreement is of benefit to the University as well as any foreseeable risks:

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