UNIVERSITY OF LOUISVILLE FOUNDATION, ULH, INC. CONFLICT OF INTEREST STATEMENT YEAR 7/1/2015 - 6/30/2016 Organization UNIVERSITY OF LOUISVILLE FOUNDATION, ULHI BOT Name of Individual (Ii-m Signature 1. Other than an employment relationship, do you or a family member conduct business with the ULF, Business transactions include, but are not limited to contracts of sale, lease, license and performance of services, whether initiated during the ULF, ULi-l tax year or ongoing from a prior year. Business transactions also include joint ventures in which either the pro?ts or capital interest of the ULF, ULH and of the interested person exceeds 10%. if ?Yes,? describe your business transaction(s) with the ULF, ULH: 2. Do you or a family member own 3596 of an entity (C-corporation, S?corporation, Partnership, LLC or other entity type(s), directly or indirectly, that conducts business with the ULF, - If "Yes,? describe your business transaction(s) with the ULF, ULH: Page 1 Of 4 DIE El entity (C-corporation, S-corporation, Partnership, LLC or other entity type), directly or indirectly, that conducts business with the ULF, 3. Do you or a family member, in combination with other "interested person(s?Yes," describe your business transaction(s) with the ULF, ULH: 4. Do you or a family member, serve as an of?cer, director, trustee, or key employee or an entity that does business with the ULF, If "Yes,? describe your business transactionls) with the ULF, ULH: Bowsg ewe w? ow: 95%. 5. Do you or a family member serve as a partner, member, or shareholder of an entity (with Cl ownership interest in excess of 5% of a partnership or professional corporation) that conducts business with the ULF, 0 If "Yes," describe your business transaction(s) with the ULF, ULH: Page 2 of 4 6. Did a family member receive a compensation payment in excess of $10,000 from the ULF, J85 If "Yes," explain: QM ALLOWMLQ 7. Did you or a family member receive grants or other assistance, including provision of goods, services, or use of facilities from the ULF, Grants include scholarships, fellowships, internships, prizes, and awards. a If "Yes," explain: 8. Do you have 35% control in an entity that received grants or other assistance, including provision of goods, services, or use of facilities from the ULF, If "Yes," explain: 9. Do you have any loans to or from the ULF, 0 If "Yes," explain. 10. Are you aware of any excess benefit transactions to report? An excess benefit transaction is where the ULF, ULH directly or indirectly provided an economic bene?t where the value of the bene?t exceeds the value of the consideration received by the ULF, ULH. Page 3 of 4 If "Yes," explain. Business and Family Relationships with Interested Persons 11. Do you have a family or business relationship with any other officer, director, trustee, or key . employee of the ULF, For each family and business relationship, identify the persons and indicate family or business relationship. Page 4 of 4 Attestation and Disclosure Form Attestation and DiSCIOsure Form This electronic system combines the annual attestation to the Code of Conduct with the disclosure form. The intent of the disclosure is to help you identify external interests? and activities you have that might affect or be affected by the roles you perform at the University of Louisville or under the auspices of the University of Louisville (Institution). This annual disclosure is collected to comply with federal regulations, state statutes and University of Louisville Policies. The main goals of these regulations. statutes and policies are to assure that a Covered Individual?s external interests* and activities do not compromise the integrity of academic, business, clinical and research missions of the Institution and to maintain the public trust through disclosure and management of real or perceived con?icts of interest. These regulations, statutes and policies may not prohibit external interests" that might bene?t employees, but they do require that they are fully reported to the Institution. reviewed and managed as appropriate. Code of Conduct Full Text of the Code of Conduct is located at: Standards of Conduct - Act Ethically and with Integrity - Be Fair and Respectful to Others - Manage Responsibly - Protect and Preserve University Resources - Promote a Culture of Compliance - Preserve Academic Freedom and Meet Academic Responsibilities - Ethically Conduct Teaching and Research - Avoid Con?icts of Interest and Commitment Carefully Manage Public, Private, and Confidential Information - Promote Health and Safety in the Workplace I con?rm that have read the University of Louisville Code of Conduct understand it, and I agree to abide by the Standards of Conduct outlined in the Code so long as I remain a Covered Individual with the University of Louisville. The ICC will be noti?ed of your response. ANNUAL DISCLOSURE FORM Information provided pursuant to this requirement is considered con?dential. The following statements apply to you as a Covered Individual at the University of Louisville. The term ?sponsor" includes any *External Entity (other than University of Louisville or one of its Associated Organizations - University of Louisville Research Foundation, University of Louisville Foundation, University of Louisville Athletic Association) that supports Institution activities. "Support" means providing anything of value funds, supplies, equipment, staff, etc.), regardless of whether restricted or unrestricted. Covered Individuals are responsible for knowing, understanding, and complying with this procedure as it relates to their role, position, employment or enrollment at the Institution; Breaches of this procedure include, but are not limited to, failing to submit an ADF, intentionally submitting an incomplete. erroneous or misleading ADF, failing to provide additional information as required by the Appropriate Authority or the Con?ict of Interest Of?ce, or failing to follow an approved plan for managing, reducing or eliminating a potential con?ict. A violation of this procedure. failure to complete thisquestionnaire or violation of federal regulations, state statutes or University of Louisville policies may result in sanctions, corrective measures and appropriate disciplinary actions. up to and including termination as determined by existing Institution policies. Full Name: James Ramsey What is your employment status with UofL? --.-Full Time employee (0.8 FTE or greater) OPart Time Employee (includes Lecturer and Instructor designations) OTemporary or Intermittent Employee OStudent OGratis Faculty OAf?liated Researcher (primary employment elsewhere, but listed on of research projects) Please clarify the roles you hold at the institution, even in a temporary capacity. The following roles are currently assigned to your pro?le. Role Name President Role Name No role(s) have been assigned Employee's Direct Supervisor (Appropriate Authority) UL Board of Trustees Provide the Full Name, Title and UnitlDepartment of all Immediate Family Members employed by the Institution and your relation to him/her. Click "Add Row" to enter Immediate Family Member information below Immediate Family ., - Title Unit/Department - Your Relationship to Member Full Name- him/her No records have been added. Disclosure Questions The following questions relate to your role(s) at the University of Louisville. Please only include those external activities that are related to your role(s) at the University of Louisville or those external entities that conduct transactions with the University of Louisville or one of its associated organizations (ULF, ULAA, ULRF). Do you, your spouse or dependent child have a role, relationship or interest in a Public, For Pro?t Entity? (Entities commonly traded on a stock exchange) Common Examples of Roles, Relationships and Interests: Equity, IP interests/royalties, Speaker?s Bureau, Honorarium, Of?cer/Board Position, Compensation, Consulting, Vendor! Contractor providing goods or services to the University Exclusions: Holdings of Mutual Funds Yes ONO a. For each Public, For Pro?t Entity with which you, your spouse or dependent child(ren) has a role, relationship, and lor interest, please provide the following. Each field marked with an asterisk is required. Entry1 *Name of External Entity (Case Sensitive) Texas Roadhouse *Nature of Institutional interaction(s) with External Entity (check all that apply) Business Academic Clinical Research *Role, Relationship, Interest (check all that apply) Own Publicly traded Stock in entity Have right to deferred compensation from entity IP rights licensed/optioned to entity Receive royalties from entity Serve on Board of Directors or equivalent (regardless of compensation) Perform speaker's bureau activities for entity (regardless of compensation) Perform consultant/adviser activites (regardless of compensation) Serve on Advisory Board (regardless of compensation) *In the aggregatelthe approximate value of your, Serve in of?cer role for entity (regardless of compensation) your spouse's and dependent realtionship with this external entity in the past 12 months was: *Do you expect the approximate value of your, your spouse's and dependent relationship in the external Entity for the next year to e: *Does this external entity currently provide support for any research, creative or scholarly actvity in which you may be involved? OYes ?No *Do you, your spouse, or dependent child(ren) design research protocols on behalf of the external entity? *Do you, your spouse or dependent child(ren) have any intellectual property that has been licensed to or optioned by the external (entity? *Do you or your spouse prescribe, use or implant products, eg. drugs or devices. made by this external entity? *Do you or your spouse refer patients to this external entity for products, goods and /or services? *As part of yourjob duties are you involved in purchasing or procurement decisions regarding this external entity's products? This may be by providing advice or consultation regarding the purchase, use or selection of products. goods or services. OYes ?No OYes ?No OYes @No OYes ?No OYes ?No Please use this space to provide comments or provide additional information about your relationship with this external entity Entry2 *Name of External Entity (Case Sensitive) . . *Nature of Institutional interaction(s) with External Entity (check all that apply) *Role, Relationship, Interest (check all that apply) *In the aggregate. the approximate value of your, your spouse?s and dependent realtionship with this external entity in the past 12 months was: *Do you expect the approximate value of your, your spouse's and dependent relationship in the external Entity for the next year to e: *Does this external entity currently provide support for any research, creative or scholarly actvity in which you may be involved?) *Do you, your spouse, or dependent child(ren) design research protocols on behalf of the external entity? 7 *Do you, your spouse or dependent child(ren) have any intellectual property that has been licensed to or optioned by the external entity? *Do you or your spouse prescribe, use or implant products, e.g. drugsor devices. made by this external entity? *Do you or your spouse refer patients to this external entity for products, goods and lor services? *As part of yourjob duties are you involved in 7 decisions regarding this external entity's products? ?This may be by providing advice or consultation regarding the purchase. use or selection of products. goods or services. Advisory Board Business Academic Clinical Research Own Publicly traded Stock in entity Have right to deferred compensation from entity IP rights. licensed/optioned to entity Receive royalties from entity Serve on Board of Directors or equivalent (regardless of compensation) Perform speaker's bureau activities for entity (regardless of compensation) Perform consultant/advisor activites (regardless of compensation) Serve on Advisory Board (regardless of compensation) Serve in of?cer role for entity (regardless ofcompensation) OYes @No A OYes @No OYes @No OYes ?No OYes ?No . OYes ?No purchasing or procurement Please use this Space to provide comments or provide additional information about your relationship with this external entity stipend is donated for an engineering scholarship Do you, your spouse or dependent child have a role, relationship or interest in a Private, For Pro?t Entity? (includes start up companies) Common Examples of Roles, Relationships and Interests: Equity, IP interests/royalties. Speaker's Bureau, Honorarium, Of?cerlBoard Position, Compensation, Consulting, Vendor! Contractor providing goods or services to the University OYes Do you, your Spouse or dependent child have a role, relationship (beyond membership) or interest in a Not For Pro?t Entity? (Foundations, Service Organizations, Professional Societies, etc). Common Examples of Roles, Relationships, and Interests: Equity, IP interests/royalties, Speaker's Bureau, Honorarium, Of?cer/Board Position, Compensation, Consulting, Vendor! Contractor providing goods or services to the University e-Yes ONO For each Not For Pro?t Entity with which you, your spouse or dependent child(ren) has a role, relationship, and I or interest, please provide the following. Each ?eld marked with an asterisk is required. Entry1 *Name of External Entity (Case Sensitive) *Nature of Institutional interaction(s) with External Entity (check all that apply) *Role, Relationship, lnterest (check all that apply) *In the aggregate. the approximate value of your, your spouse's and dependent realtionship with this external entity in the past 12 months was: ?Do you expect the approximate value of your, your spouse's and dependent relationship in the external entity for the next year to be: *What is the website address for the entity? *What is the principal business address of the entity *Does this entity have funded staff? *Do students you teach or employees you supervise also participate in the activities of this entity? *Please use this space to provide comments or provide additional information about your relationship with this external entity Do you, your spouse or dependent child receive anything of value ("gift") greater than $25 per year related to your *role(s) within the Institution, from an *External Entity that provides goods, services and/or funds to the University of What is the name of the External Not for Pro?t Entity? University of Louisville Foundation Academic Business Clinical Research Serve on the Board of Directors or equivalent (regardless of compensation) Serve on Advisory Board (regardless of compensation) Serve on Speaker's Bureau (regardless of compensation) Serve in Of?cer role (regardless of compensation) Have Ownership interests in Entity Founder of Entity Consultant to Entity (regardless of compensation) None of the above 2301 3rd Street Yes Mrs. Ramsey recieves a President of the ULF car allowance Louisville, or any of its Associated Organizations? Common Examples: free meals, discounted conference registration fees, free or discounted tickets to entertainment events, software, gift cards /certi?cates, or other tangible items. Discounts received through the employee bene?ts programs do not need to be reported here. Items related to sponsor provided travel should be disclosed on the travel question, not here. "Ii-Yes For each gift over $25 received, please provide the following. Each ?eld marked with an asterisk is required. Entry1 *External Entity giving gift: Mp0 promotions *Gift from External Entity Gift Cards Certi?cates If gift selected is meals, *Approximate Value 1 Amount was the meal related to 3 CME event or FDA required training? lOYes Previous 12 Months Upcoming 12 Months *lndividual who received Self Family Member ls/was this gift related to a OYes 1N0 Product training Activity? Do you or your spouse employ Covered Individuals or students in an External Entity that you also supervise/mentor/instruct in your institutional OYes No Do you have Institutional Responsibility to make Institutional resource decisions that also involve an *External Entity in which you, your spouse or your dependent child hold an *lnterest? OYes Do Covered Individuals under your direct supervision engage in Institutional activities with an *External Entity in which you, your spouse or dependent child hold an *lnterest? OYes 5-1=No ADDITIONAL. DISCLOSURES Do you. your spouse, or dependent child(ren) have any external *Interests, activities or Relationships that have not been identi?ed in the above questions? Entry1 Aggregate ?nancial value of external interest, activity or relationship Please provide a detailed decsription of the external interest. activity or relationship $0-$4999 RECOMMENDATION TO UNIVERSITY OF LOUISVILLE RESEARCH FOUNDATION, INC. BOARD OF DIRECTORS REGARDING AUTHORIZATION OF THE PRESIDENT OR HIS DESIGNEE TO REPRESENT ULRF ON INTELLECTUAL PROPERTY COMMERCIALIZATION November 21, 2013 RECOMMENDATION: The Chair recommends the President, or his designee. serve on the Boards of Directors for the following companies: Advanced Cancer Therapeutics (ACT) ApoVax Edumedics Intrepid Bioinformatics Laboratories Rhinocyte as representing the ULRF's intellectual property (IP) investment in these commercialized entities. The President's service is representational only and any distribution to board members by these companies from liquidity events, stock authorization. dividend payments, or company actions to increase the worth of the IP will accrue to the ULRF. Additionally. the Chair recommends this action extend to future companies the ULRF has IP value in and re?ects the representational position of the President or his designee. BACKGROUND: A sample of the companies the ULRF has intellectual property equity from University of Louisville Faculty follows: ACT ApoVax Edumedics Intrepid Bioinformatics Laboratories Rhinocyte BOARD ACTION: Passed: Did not Pass: Other: Date: Asst. Secretary ADDITIONAL COMMENTS 1. On March 13, 2015 an email was recieved from Adrienne in the Compliance Of?ce stating, that Dr. Ramsey did not have to complete the university ADF form. 2. According to Board requirements Dr. Ramsey's completed 00] forms for ULF, ULRF and QCCT Boards are on file. ACKNOWLEDGMENTS I hereby acknowledge: that all the aforementioned statements and information provided in this ADF are true. accurate and complete to the best of my knowledge and belief; that all the aforementioned statements and information provided in this ADF indicate all external interests and activities with regard to my role(s) at the Institution; that I may need to provide additional information, as needed. in order for the Institution to determine the existence of a con?ict of interest and to manage said con?ict of interest; that this disclosure and any subsequent management plan may be shared with af?liated research sites where I may seek to conduct research; my continuing obligation to submit an amended/revised ADF within 30 days if any of the above information changes, new information becomes available and/or new external interests or activities arise. M, . -m . here fd'con?nn proceed to signoff, and complete the submissidn