Institutional Declaration Form for Subrecipients/External

Institutional Declaration Form for Subrecipients/External
Investigators for Research Funded by the US Public Health Service (PHS) including NIH
Part 1: Subrecipient/External Investigator and Institution Information
Institution Name
Institution Address
DUNS #
Investigators (includes
Date
anyone who is responsible for
the design, conduct or
reporting of PHS funded
research. Please add an
additional page if required.
Subrecipient/External PI
Investigator
Investigator
Part 2: Proposal Information
Title of Proposal
Fund# (if known)
McGill PI
Part 3: Institutional Financial Conflict of Interest Policy Information
 My institution DOES HAVE a PHS FCOI policy that will be followed by all subrecipient/external investigators.
My institution will provide information related to any identified FCOIs to McGill prior to the execution of
the subaward, or in cases where disclosure is made during the course of the subaward, within 45 days of
receiving disclosure.
 My institution either DOES NOT HAVE a PHS FCOI policy or it does but the subrecipient/external
Investigators have chosen to follow McGill’s PHS FCOI policy.
Part 4: Signature
I certify that the information listed above is true, complete and accurate to the best of my knowledge, and that
I am authorized to sign for the subrecipient/external institution listed above. My institution is knowledgeable
about the PHS FCOI Regulations (42 CFR Part 50 and 45 CFR Part 94), and we are prepared to enter into an
inter-institutional agreement that requires adherence to those Regulations.
Signature:
Date:
Printed Name:
Title:
E-mail:
Upon completion, return this form to your Grants Officer at the Office of Sponsored Research (OSR).
October 29, 2015
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