https://iris.louisville.edu/System_Data_Form_Collect_Printable.jsp?DA... Submitted 03/09/2015 Attestation and Disclosure 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 conflicts of interest. These regulations, statutes and policies may not prohibit external interests* that might benefit 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: http://louisville.edu/compliance/ico/code 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 Conflicts of Interest and Commitment Carefully Manage Public, Private, and Confidential Information Promote Health and Safety in the Workplace I confirm that I have read the University of Louisville Code of Conduct (“Code”), 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. ● Yes ○ No The ICO will be notified of your response. ANNUAL DISCLOSURE FORM Information provided pursuant to this requirement is considered confidential. 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 1 of 5 2/16/2016 3:58 PM https://iris.louisville.edu/System_Data_Form_Collect_Printable.jsp?DA... Foundation, University of Louisville Athletic Association) that supports Institution activities. “Support” means providing anything of value (e.g., 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 Conflict of Interest Office, or failing to follow an approved plan for managing, reducing or eliminating a potential conflict. A violation of this procedure, failure to complete this questionnaire 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: Kathleen M Smith Please clarify the roles you hold at the institution, even in a temporary capacity. The following roles are currently assigned to your profile. Role Name No role(s) have been assigned Role Name Department Chair University Compliance Officers Vice President, Assoc VP, Asst VP Employee's Direct Supervisor (Appropriate Authority) James R. Ramsey Provide the Full Name, Title and Unit/Department 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 Member Full Name Mark E. Smith 2 of 5 Title JD Unit/Department Business/Accountancy Your Relationship to him/her Spouse 2/16/2016 3:58 PM https://iris.louisville.edu/System_Data_Form_Collect_Printable.jsp?DA... Anita E. Smith Ms. Athletics Child (Step, In-Law, Biological, Foster) Disclosure Questions Do you, your spouse or dependent child have a role, relationship or interest in Public, For Profit Entity? (Entities commonly traded on a stock exchange) Common Examples of Roles, Relationships and Interests: Equity, IP interests/royalties, Speaker's Bureau, Honorarium, Officer/Board Position, Compensation, Consulting, Vendor/ Contractor providing goods or services to the University Exclusions: Holdings of Mutual Funds ○ Yes ● No Do you, your spouse or dependent child have a role, relationship or interest in Private, For Profit Entity? (includes start up companies) Common Examples of Roles, Relationships and Interests: Equity, IP interests/royalties, Speaker's Bureau, Honorarium, Officer/Board Position, Compensation, Consulting, Vendor/ Contractor providing goods or services to the University ○ Yes ● No Do you, your spouse or dependent child have a role, relationship or interest in Not For Profit Entity? (Foundations, Service Organizations, Professional Societies, etc) Common Examples of Roles, Relationships, and Interests: Equity, IP interests/royalties, Speaker's Bureau, Honorarium, Officer/Board Position, Compensation, Consulting, Vendor/ Contractor providing goods or services to the University ○ Yes ● No 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 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 / certificates, or other tangible items. Discounts received through the employee benefits programs do not need to be reported here.) 3 of 5 2/16/2016 3:58 PM https://iris.louisville.edu/System_Data_Form_Collect_Printable.jsp?DA... ● Yes ○ No For each gift over $25 received, please provide the following. Each field marked with an asterisk is required. Entry 1 *Gift from External Entity *Approximate Value / Amount Gift Cards / Certificates Previous 12 Months 200 Upcoming 12 Months 0 *Individual who received gift Self Family Member *External Entity giving gift: NTS-$100 card; Barnes $100 card Do you or your spouse employ Covered Individuals or students in an External Entity that you also supervise/mentor/instruct in your institutional role(s)? ○ Yes ● 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 *Interest? ○ Yes ● No 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 *Interest? ○ Yes ● No ADDITIONAL DISCLOSURES Do you, your spouse, or dependent child(ren) have any external *Interests, activities or Relationships that have not been identified in the above questions? ○ Yes ● No ACKNOWLEDGMENTS I hereby acknowledge: 1. that all the aforementioned statements and information provided in this ADF are true, accurate and 4 of 5 2/16/2016 3:58 PM https://iris.louisville.edu/System_Data_Form_Collect_Printable.jsp?DA... complete to the best of my knowledge and belief; 2. 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; 3. that I may need to provide additional information, as needed, in order for the Institution to determine the existence of a conflict of interest and to manage said conflict of interest; 4. that this disclosure and any subsequent management plan may be shared with affiliated research sites where I may seek to conduct research; 5. 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. ● Click here to confirm, proceed to signoff, and complete the submission of your ADF. 5 of 5 2/16/2016 3:58 PM