APPENDIX M

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STATEMENT OF SIGNIFICANT FINANCIAL INTEREST
The University of Texas health Science Center at San Antonio

Investigator Completing This Form: _____________________________________________
Department: _____________________________________________
Title of Application: _____________________________________________
Principal Investigator on Application: _____________________________________________
Granting Agency: _____________________ Date of Application: ______________________

This disclosure information form should be completed in conjunction with The University of Texas Health Science Center at San Antonio "Policy and Procedures for Promoting Objectivity in Research by Managing, Reducing or Eliminating Conflicts of Interest" (the "Policy"). this form cannot be completed without reference to the definitions in the policy.

Each Investigator must submit this form to Grants Management with each federal research application or extension request.

1. List all entities other than those excluded by Section III of the Policy in which you or a family member hold an equity interest of $10,000 or more, or a 5% ownership interest. If none, please indicate. (Use additional pages for other business entities where needed.)

  1. Entity:_______________________________________________________________

    Description of Interest:___________________________________________________

  2. Entity:_______________________________________________________________

    Description of Interest:___________________________________________________

  3. Entity:_______________________________________________________________

    Description of Interest:___________________________________________________

2. List all entities other than those excluded by Section III of the Policy that provide sources of income of $10,000 or more to you or a family member. Provide a brief explanation of that income (i.e., salary, consultant or advisory board payments, royalties, etc.) If none, please indicate. (Use additional pages as needed.)

    (1) ________________________________________________________________________

    (2) ________________________________________________________________________

    (3) ________________________________________________________________________

    (4) ________________________________________________________________________

I have completed this Statement of Significant Financial Interests to the best of my ability after having read The University of Texas Health Science Center at San Antonio "Policy and Procedures for Promoting Objectivity in Research by Managing, Reducing or Eliminating Conflicts of Interest."

Signature:___________________________________________Date:________________________
Distribution: Submit to Grants management (UTHSCSA 11/15/95) (Please reproduce this form as necessary.)