ATTESTATION AND DISCLOSURE FORM (2012 Cycle) Information provided pursuant to this requirement is considered con?dential Student Employee ID: Department or Division: Health Affairs Last Name: Dunn Campus Telephone: 852-6201 First Name: David E-mail address; dldunn01@iouisvilie.edu Covered Individual?s Direct Supervisor Presidentlames Ramsev (Appropriate Authority) The intent of this questionnaire 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 report is being conducted to comply with federal regulations (DHHS, PHS, and NSF Regulations, 21 CFR Parts 54, 312, 314, 320, 330, 601, 807, 812, 814, and 860, and OMB Circular A-110), state statutes (KRS 45A.340, 164.367, 164.390, 164.821) and University of Louisville Policies (Addressing Potential Individual Conflict of Interest Policy and Procedures and Addressing Potential Institutional Conflict of Interest Policy and Procedures). 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 relationships that might bene?t employees, but they do require that they are fully reported to the Institution, reviewed and managed as appropriate. The following statements apply to you as an employee or affiliated researcher at the University of Louisville. The term includes you, as 3 Covered individual, and your immediate family membersl. The term "sponsor" includes any entity (other than University of Louisville or one of its affiliated organizations, University of Louisville Research Foundation, University of Louisville Foundation, University of Louisville Athletic Association) that supports university activities. Note that private practice plans/PSCS and their affiliated foundations are not considered affiliated organizations for these purposes. ?Support? means providing anything of value funds, supplies, equipment, staff, etc), regardless of whether restricted or unrestricted. The term ?vendor? means an individual or entity that provides goods and or services to the University of Louisville under contract (written or verbal). 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 ADP, intentionally submitting an incomplete, erroneous or misleading ADF, failing to provide additional information as required by the Appropriate Authority, 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. if you are at all unsure whether your particular situation constitutes an external interest, it is advisable to err on the side of reporting. Based on your responses, you may be contacted to provide additional explanation or information. if you require assistance, please contact the Conflict of Interest Office at COIOFF@IouisvilIe.edu or 852-1371 852-7612. Research specific questions should be directed to the Of?ce of Research Integrity at ori@iouisvilie.edu or 852-2454. 1 immediate family member shall mean the Covered individual?s biological, foster or adoptive parent, a stepparent, spouse, qualifying adult, a biological, adoptive or foster child, a step child, a legal ward or a person whom the covered individual has (or had during the person's youth) daily responsibility and financial support, mother, father, brother, sister, son, daughter, mother-in-law, father-in-iaw, brother?in-law, sister?in-Iaw, son-in?law, daughter?in?law, grandparents, and grandchildren of both the covered individual and spouse and or qualifying adult. A qualifying adult must be over 18 years of age, and, if a blood relative (or relative by adoption or marriage) must be of the same or younger generation of the Covered individual (as used in KRS 391.010), and, must be residing in the covered individuai's household and have done so for a period of at least 12 months, and, must be financially interdependent (for example, have ioint checking account orjoint mortgage) for 12 months or longer, and, must be unmarried. Part A: Code of Conduct Full Text of the Code of Conduct located at: Standards of Conduct 0 Act Ethically and with Integrity - Be Fair and Respectful to Others 0 Ethically Conduct Teaching and Research 0 Manage Responsibly - Avoid Conflicts of Interest and Commitment 0 Protect and Preserve University Resources 0 Carefully Manage Public, Private, and 0 Promote a Culture of Compliance Confidential Information a Preserve Academic Freedom and Meet 0 Promote Health and safety in the Workplace Academic Responsibilities I confirm that I 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. Part B: Disclosure Form 1. Type of Disclosure Annual [:IAmendment/Revision 2. Provide Name, title and department of all immediate family members employed by the University of Louisville Immediate Family Member Title Department Relationship to Covered individual Professor 5 Part 3.1: Business The following disclosure questions are to be answered by ALL Covered Individuals and are a condition of your Term of Appointment. When you answer each question, consider the following time interval: the previous 12 months and the anticipation of the coming 12 months (a two year window). 1. Do you and/or your immediate family members have a relationship with an Entity that is engaged in a business relationship with the University of Louisville or any of its Associated Organizations (University of Louisville Foundation, University of Louisville Research Foundation, University of Louisville Athletic Association)? DYes No 2. Do you or your Immediate Family Members collectively receive anything of value totaling more than $25 per year ("gift") from a single Entity that is engaged in a business relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, (Examples of gifts would include - free meals, lodging, travel, 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.) [:IYes END 3. Do you or your Immediate Family Members employ Covered Individuals or students in an Entity that is engaged in a business relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, DYes Jump to Part C.1 Business 1. 3. 4. 5. 6. 7. Part 32: Academics This section must be completed by all Covered Individuals involved in the academic operations of the University of Louisville. Involved in academic operations includes: teaching a course, serving as an advisor to students or a student organization, serving as a Faculty Mentor/Thesis/Dissertation Advisor Member or Instructor (includes an enrollment, award, scholarship or graduation committees). When you answer each question, consider the following time interval: the previous 12 months and the anticipation of the coming 12 months (a two year window). Do you or your Immediate Family Members have a relationship with an Entity that is engaged in an academic relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, [:IYes gNo Do you or your Immediate Family Members collectively receive anything of value totaling more than $25 per year ("gift) from an Entity that is engaged in an academic relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, (Examples of gifts would include - free meals, lodging, travel, discounted conference registration fees, free or discounted tickets to entertainment events, software, gift cards certificates, free textbooks, or other tangible items. Receipt of examination copies of textbooks do not need to be reported here.) [Has No Do you require or recommend your own, your supervisor?s or your Immediate Family Members' textbooks or other teaching aids? (This includes course pack, lab manual, materials, software or equipment to be used with University of Louisville instructional programs - "academic resource?) KING Do you or your Immediate Family Members serve as Faculty Mentor, Thesis or Dissertation Advisor, Committee Member or Instructor for a student that you also employ? DYes Do you or an Immediate Family Member serve as Faculty Mentor, Thesis or Dissertation Advisor, Committee Member or Instructor for a student that has an interest in an Entity in which you or your Immediate Family Members also hold a relationship? [:JYes No Do you serve as Faculty Mentor, Thesis or Dissertation Advisor, Committee Member or Instructor for an Immediate Family Member? DYes IZNO Do you serve as Faculty Mentor, Thesis or Dissertation Advisor, Committee Member or Instructor for a student with whom you have an external personal or professional relationship? END Jump to Part C.2 Academics Part 33: Clinical This section must be completed by all Covered Individuals involved in the clinical operations of the University of Louisville. Clinical operations include: work, clinical practice, clinical research and education of University of Louisville clinical students, residents and fellows in all hospital and office settings owned, operated by, or rented by or otherwise under the control of entities using the UofL Health Care name. When you answer each question, consider the following time interval: the previous 12 months and the anticipation ofthe coming 12 months (a two year window). 1. Do you or your'lmmediate Family Members have a relationship with an Entity that is engaged in a clinical relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, (This includes providing or having the potential to provide support or advice, consulting, reviews, or assistance in evaluating the selection that is intended to result in the use or acquisition of products or services that impact the clinical operations of UofL Health Care or to which you make clinical referrals.) : Yes ?rm: Do you or your Immediate Family Members collectively receive anything of value totaling more than $25 per year (?gift?) from an Entity that is engaged in a clinical relationship with the University of Louisville or any of its Associated Organizations (ULF, ULRF, (Examples of gifts would include - free meals, lodging or travel, discounted conference/ registration fees, free or discounted tickets to entertainment events, software, gift cards certificates, or other tangible items.) EYES Ewe Do you or your Immediate Family Members employ Covered Individuals or students in an Entity that is engaged in a clinical relationship with the University of Louisville or any of its Associated Organizations (U LF, ULRF, ULAA) I: Yes No Jump to Part C.3 Clinical Part 8.4: Research and Scholarly Activity This section must be completed by ail Covered individuals involved in research or scholarly activity, which being listed as an investigator, sub?investigator or study personnel, on a protocol that is submitted to the IACUC and or being listed on a Food and Drug Administration (FDA) 1572 form; collecting and or presenting original data, in any form; development of originai materials; presentation of original materials in a public forum outside the University of Louisville, listed as study/project personnel on a sponsored project or award contract, included on the budget of a sponsored program budget, have a biographical sketch included in a sponsored program proposal, contract solicitation. When you answer each question, consider the previous 12 months and the anticipation of the coming 12 months (a two year window). 1. Do you or your Immediate Family Members have a relationship with an Entity that supports the research or scholarly activity of yourself or of someone under your supervision or that is a competitor to an Entity that supports the research or scholarly activity of yourself or of someone under your supervision? (Examples would include ownership, stock options, officer or board positions, honoraria for lectures workshops, teaching engagements, seminars or service on advisory boards.) I:)Yes EN0 2. Do you or your Immediate Family Members coliectively receive anything of value totaling more than $25 per year (?gift?) from a single Entity that is engaged in a research or scholarly activity relationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, (Examples of gifts would inciude - free meals, lodging, travel, discounted conference registration fees, free or discounted tickets to entertainment events, software, gift cards certificates, or other tangibie items. Discounts received through the employee Enefits programs do not need to be reported hereyour immediate Family Members hoid a proprietary interest (pending patent, issued patent, trademark, trade secret, copyright, invention, licensing agreement)related to the research or schoiariy activity of yourself or of someone under your supervision? (Note: if the interest exists, but no funds have yet been received, the answer wouid still be Yes 4. Do you or your immediate Family Members receive direct payments or entitiements to direct payments in connection with the research or scholarly activity of yourself or of someone under your supervision? (Direct payments do not include payments for sponsored research agreements made to the University of Louisville Research Foundation.) gYes END 5. Do students, interns, residents, fellows, graduate students, or other trainees under your supervision or mentorship participate in University of Louisville research or scholarly activities in which you or your immediate Family Members have an externai interest? Eli/es KING 6. Do you or your immediate Family Members employ Covered individuals or students in an Entity that is engaged in a research or scholarly activity reiationship with the University of Louisville, or any of its Associated Organizations (ULF, ULRF, [:lYes No 7. Do you serve on an internal or external body with jurisdiction to award or distribute government funds committees of FDA, or other governmental agencies, private professional or regulatory body) where participation would reasonably appear to be influenced by the presence or existence of an external interest or relationship? I:]Yes IZNO 8. Do you or your Immediate Family Members receive sponsored or reimbursed travel directly from an Entity that supports your research? DYes No 7 Jump to Part C.4 Research and Scholarly Activity Part B.5 Institutional This section must be completed by ALL Institutional Officials. "Institutional Official" means persons holding administrator positions, including those holding these positions in a temporary capacity. This term includes, but is not limited to individuals serving as: Deans, Associate Deans, and Assistant Deans; Institute and Center Directors; General Counsel; University Compliance Officers; Director of Audit Services; Provost, Vice Provosts, Associate Vice Provosts, and Assistant Vice Provosts; President, Executive Vice Presidents, Senior Vice Presidents, Vice Presidents, Associate Vice Presidents, and Assistant Vice Presidents; and chairs of the Institutional Review Board, Institutional Biosafety Committee, Institutional Animal Care and Use Committee, Conflict Review Board and other similar committees that might be created in the future. When you answer each question, consider the following time interval: the previous 12 months and the anticipation of the coming 12 months (a two year window). 1. Do you have Institutional responsibility to make University of Louisville resource decisions (facilities, funds, personnel) for academic, business, clinical, research or scholarly activity relationships that also involve an Entity in which you or your Immediate Family Members hold a relationship? DYes No 2. Do Covered Individuals under your direct supervision engage in academic, business, clinical, research or scholarly activities with an Entity in which you or your Immediate Family Members hold a controlling interest or hold a relationship? EYes DNO Jump to Part C.5 Institutional 1. Do you have any external interests or activities that have not been covered in the above sections? l: Yes No If Yes, please provide a description of the external interest, activity or relationship below PART C: DISCLOSURE or EXTERNAL INTERESTS Part C.1 Business (Questions to he answered for each entity in which you or an immediate famiiy member has a reiationship) C.1.1. What relationships do you and/or your immediate family members have with the Entity that is engaged in business transactions with of or one of its affiliated organizations? Name of Entity#1 The McGraw?Hill Companies. Type of Entity No Yes Public Private VA [3 For Profit [3 Notfor Profit 211 CI Relationships (check all that apply) Approximate Value es Previous 12 months Expected in next 12 months UL Affiliation (UL, ULF, ULRF, ULAA) individual holding relationship or 2 Philanthropic Donation Consulting Ownership Employment Training Service Grantlnon-research) Equipment Gift Equipment Loan Other (describe) 000 Uofl DLD Transaction Time Period es Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) Ks EIZID 2 is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the institution? if yes, are the goods and or services available commercially, from other sources? ED EJEJ Name of Entity#2 I Type of Entity No Yes Public [3 Private For Profit - A El Not for Profit Relationships {check all that apply) Approximate Value es Previous 12 months 5- 0 2 Expected in next 12 months UL A?iliation (UL, ULF, ULRF, ULAA) Individual holding relationship Cl or Philanthropic Donation Consulting Ownership Employment Training Service Gran tinon-research} Equipment Gift Equipment Loan Other (describe) Transaction Time Period Yes Previous 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the institution if yes, are the goods and or services available commercially, from other sources? Upcoming 12 months 0 2D DD ED DD Name of Entity#3 Type of Entity Public Private For Profit Not for Profit Relationships (check all that apply) 0 85 No Yes Approximate Value Previous 12 months Expected in next 12 months UL Affiliation (UL, ULF, ULRF, ULAA) individual holding relationship Cl or Philanthropic Donation Consulting Ownership Employment Training Service Grant(non?research) Equipment Gift Equipment Loan Other (describe) Transaction 85 Time Period Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the Institution? If yes, are the goods and or services available commercially, from other sources? 0 ED DU ED DD Name of Entity#4 I Type of Entity No Yes Public [3 Private For Profit El Not for Pro?t Relationships {check all that apply) Approximate Value es Previous 12 months 2 Expected in next 12 months UL Affiliation (UL, ULF, ULRF, Individual holding relationship Cl or IFM Philanthropic Donation Consulting Ownership Employment Training Service Grantlnon-research} Equipment Gift Equipment Loan Other (describe) Transaction Time Period es Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the institution if yes, are the goods and or services available commercially, from other sources? gm DD ED EJIZI C.1.2. What gifts have you and/or your immediate family members received from an Entity that is engaged in business transactions with of of one of its affiliated organizations? Gifts (check all that apply} 0 2 Approximate Value Previous 12 months Expected in next 12 months u, it Entity providing Gift individual holding relationship Cl or Meals Travel or Lodging Meeting Conference Registrations Tickets to Entertainment Events Software Gift Cards Certificates Other (describe) (5.1.3. In what capacity do you or your immediate family members employ faculty, staff, students or trainees in an Entity that is engaged in business transactions with the of or one of its a?iliated organizations? Employment Relationships check all that apply) 0 In List all such Covered individuals and students employed lndividuai holding relationship Cl or Employing Entity Employee full time Employee part time Employee - contract Advisor Consultant Other (describe): SUBBED C.2.1. What relationships do you and/or your immediate family members have with the external entity that is engaged in academic transactions With of or one of its a?iliated organizations? (Questions to be answered for each entity in which you or an immediate family member has a relationship) Name of Entity#1 I 1 Type of Entity Public Private For Profit Notfor Pro?t Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 months UL A?iliation (UL, ULF, individual holding relationship ULRF, ULAA) Cl or DUDE Philanthropic Donation Consulting Ownership Employment Training Service Grant(non?research} Equipment Gift Equipment Loan Other (describe) Transaction Time Period Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals Does the entity propose to rent or sell goods or to provide services to the Institution If yes, are the goods and or services available commercially, from other sources? ea in DD Name of Entity#2 I Type of Entity Public Private For Profit Notfor Profit Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 months UL Affiliation (UL, ULF, individual holding relationship ULRF, ULAA) Cl or DUDE Philanthropic Donation Consulting Ownership Employment Training Service Grant(non?research) Equipment Gift Equipment Loan Other {describe} Transaction Time Period Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the'lnstitution? if yes, are the goods and or services available commercially, from other sources? 531:: gm Eli] Name of Entity#3 I Type of Entity Public Private For Profit Not for Profit Relationships (check all that apply} DUDE Approximate Value Previous 12 months Expected in next 12 months UL Affiliation (UL, ULF, ULRF, ULAA) individual holding relationship or Philanthropic Donation Consulting Ownership Employment Training Service Grantlnon-research) Equipment Gift Equipment Loan Other (describe) Transaction Time Period Previous 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) Upcoming 12 months is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the institution if yes, are the goods and or services available commercially, from other sources? gm [:lEl ED DD Name of Entity#4 I Type of Entity Public Private For Profit Not for Profit Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 months UL Affiliation (UL, ULF, Individual holding relationship ULRF, ULAA) Cl or DUDE Philanthropic Donation Consulting Ownership Employment Training Service Gran tlnon~research) Equipment Gift Equipment Loan Other (describe) Transaction Time Period Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Receipt of Goods Receipt of Services Receipt of Funds Other (describe) is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the institution if yes, are the goods and or services available commercially, from other sources? DD 2D DD C.2.2. What gifts have you and/or your immediate family members received from an external entity that is engaged in academic transactions with of or one of its a?iliated organizations? Gifts {check all that apply) Approximate Value Previous 12 months Expected in next 12 months Entity providing Gift individual receiving gift Meals Travel or Lodging Meeting Conference Registrations Tickets to Entertainment Events Software Gift Cards Certi?cates Other (describe) C.2.3. What materials developed by yourself, your supervisor, or a member of your immediate family are required in courses taught by you at the (Questions to be answered for each course using materials developed by yourself or a member of immediate family member) Name of Course #1 Title of materials: Author (Self, Family Member, Supervisor): No Are students required to purchase the materials? If yes, are they available on reserve at the library or departmental office? Are the required materials selfvpubiished? if not self-published, is there a royalty agreement in place? is the course required for graduation? Name of Course #2 Title of materials: Author (Self, Family Member, Supervisor): No Yes Are students required to purchase the materials? if yes, are they available on reserve at the library or departmental office? Are the required materials sel?published If not sel?published, is there a royalty agreement in place? is the course required for graduation? Name of Course #3 I Title of materials: Author (Self, Family Member, Supervisor): No Yes Are students required to purchase the materials? if yes, are they available on reserve at the library or departmental o??ice? Are the required materials self?published? if not self?published, is there a royalty agreement in place? Is the course required for graduation? C.2.4. For each student that you and/or your immediate family members employ in an Entity, provide the following information: List all such of faculty, staff, Employment Relationships Individual holding relationship students and trainees within this (check all that apply) CI or category University Relationship (Committee Member includes any enroll, scholarship or graduation committees) Advisor Committee Member Mentor Advisor DInstructor [3 Committee Member Mentor Advisor Ijinstructor Committee Member Mentor Advisor Einstructor [3 Committee Member Mentor Advisor Committee Member Mentor Advisor [3 Committee Member I: Mentor Employee full time Employee part time Employee contract Advisor Consultant DECIDED Other (describe): C.2.5. What students do you serve as a Faculty Mentor/Thesis/Dissertation Advisor/Committee Member or Instructor in which the student has a controlling interest in an Entity that you and/or your immediate family members hold a relationship? List all such Advisees/Mentees Name of Entity Relationship You hold with External Entity Consultant Advisory Board [3 Contract Employee I: Board of Directors Consultant El Advisory Board Contract Employee Board of Directors Consultant Advisory Board I: Contract Employee Board of Directors El Consultant [1 Advisory Board Contract Employee [3 Board of Directors El Consultant Advisory Board Contract Employee Board of Directors Consultant El Advisory Board I: Contract Employee Board of Directors C.2.6. What members of your immediate family do you serve as a Faculty Mentor/Thesis/Dissertation Advisor/Committee Member or Instructor? Mentor [j Thesis/ Dissertation Advisor Thesis/ Dissertation Advisor El Thesis/ Dissertation Advisor Committee Member {j Committee Member I: Committee Member El instructor Mentor instructor I: Mentor El Instructor Mentor Thesis/ Dissertation Advisor Committee Member instructor Mentor Thesis/ Dissertation Advisor Committee Member I: Instructor Mentor I: Thesis/ Dissertation Advisor El Committee Member instructor C.2. 7. What students do you serve as a Faculty Mentor/TheSis/Dissertation Advisor/Committee Member or instructor as well as maintain an external professional or personal relationship? I: Mentor Thesis/ Dissertation Advisor Committee Member instructor Mentor Thesis/ Dissertation Advisor Committee Member instructor CI Mentor I: Thesis/ Dissertation Advisor Committee Member instructor Mentor {j Thesis/ Dissertation Advisor Committee Member instructor Mentor Thesis/ Dissertation Advisor Committee Member I: instructor Mentor Thesis/ Dissertation Advisor El Committee Member instructor Part C3 Clinical C.3.1. What relationships do you and/or your immediate family members have with the external entity that is engaged in clinical transactions with Of Healthcare (Questions to be answered for each entity in which you or an immediate family member has a relationship) Name of Entity#1 I I I Type of Entity Public Private For Profit Not for Profit DEED DEED Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 individual holding relationship months Cl or Philanthropic Donation Consulting Ownership Employment Training Service Grant(non-research) Equipment Gift Equipment Loon Other (describe): Transaction Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Provision of Referrals Receipt of Goods Receipt of Services Receipt of Funds Receipt of Referrals Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the of Healthcare? if yes, are the goods and or services available commercially from other sources? DD DD Name of Entity#2 Type of Entity Public Private For Profit Not for Pro?t DUDE DUDE Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 Individual holding relationship months Cl or Philanthropic Donation Consulting Ownership Employment Training Service Grant{non-research) Equipment Gift Equipment Loan Other (describe): Transaction Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Provision of Referrals Receipt of Goods Receipt of Services Receipt of Funds Receipt of Referrals Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the of Healthcare? if yes, are the goods and or services available commercialiy from other sources? @121 st: 131:: Name of Entity#3 Type of Entity Public Private For Profit Not for Pro?t DUDE DUDE Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 individual holding relationship months Cl or Philanthropic Donation Consulting Ownership Employment Training Service Grumman-research) Equipment Gift Equipment Loan Other (describe): Transaction Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Provision of Referrals Receipt of Goods Receipt of Services Receipt of Funds Receipt of Referrals Other (describe): ls the entity providing or receiving goods, services or funds in an area that you supervise, select or- evaluote services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the of Healthcare? if yes, are the goods and or services available commercially from other sources? gt: CID em DD Name of Entity,? Type of Entity Public Private For Profit Not for Profit DEED DEED Relationships (check all that apply} Approximate Value Previous 12 months Expected in next 12 individual holding relationship months i or Philanthropic Donation Consulting Ownership Employment Training Service Grantinon-research) Equipment Gift Equipment Loan Other (describe): Transaction Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Provision of Referrals Receipt of Goods Receipt of Services Receipt of Funds Receipt of Referrals Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals Does the entity propose to rent or sell goods or to provide services to the of Healthcare? if yes, are the goods and or services available commercially from other sources? :21: ea DD Name of Entity#5 Type of Entity Pub?c Private For Pro?t Not for Profit DUDE DUDE Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 Individual holding relationship months Cl or Philanthropic Donation Consulting Ownership Employment Training Service Grant(non-research) Equipment Gift Equipment Loan Other (describe): Transaction Previous 12 months Upcoming 12 months Provision of Goods Provision of Services Provision of Funds Provision of Referrals Receipt of Goods Receipt of Services Receipt of Funds Receipt of Referrals Other (describe): is the entity providing or receiving goods, services or funds in on area that you supervise, select or evaluate services, select goods or make referrals? Does the entity propose to rent or sell goods or to provide services to the of Healthcare? lfyes, are the goods and or services available commercially from other sources? 55D CID e13 CID C.3.2. What gifts have you and/or your immediate family members received from an external entity that is engaged in clinical transactions with of Healthcare? Gifts {check all that apply) Approximate Value Previous 12 months Expected in next 12 months Entity providing Gift Individual receiving gift Meals Travel or Lodging Meeting Conference Registrations Tickets to Entertainment Events Software Gift Cards Certificates Other (describe) C33. In what capacity do you and/or your immediate family members employ faculty, sta??, students or trainees in an external entity that is engaged in clinical transactions with the of Healthcare? EmpIOyment Relationships List all such of faculty, staff, students and Individual holding relationship (check all that apply) trainees employed Cl or IFM Employee full time Employee - part time Employee - contract Advisor Consultant Other (describe): Part CA Research and Scholarly Activity C.4.1. What relationships do you and/or your immediate family members have with the external entity that is engaged in research or scholarly activity transactions with of of one of its affiliated organizations? (Questions to be answered for each entity in which you or an immediate family member has a relationship) Name of Entity#1 I Type of Entity Public Private For Profit Not for Profit DUDE Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 UL A?iliation (UL, ULF, Individual holding relationship months ULRF, ULAA) Cl or Philanthropic Donation Consulting Ownership Employment (includes Chief Scientific Officer) Stock or Stock Options or other ownership interests Executive Position (President, VP,etc) Board of Directors A Training Service Grant Advisory Board Honorarium Entitlement to Deferred Compensation Payment for lectures or papers Royalties for inventions Sponsored Research Payment for product evaluation Research Supplies Gift Research Equipment Gift Research Equipment Loan Other (describe).- Activity (Check all that apply) A Time Period Previous 12 Upcoming If yes, provide applicable months 12 months IACUC, BC and or Award Animal Research Applied Research DD Bench Work Clinical Trial Human Subjects, Not Clinical Trial Preclinical Pilot Study Feasibility Study Marketing Study CME Educational Activity Activity Speaker?s Bureau Data Safety Monitoring Board Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? is the entity contributing gift funds that are under your control or of direct benefit to your research or scholarly activity to of l. or one of its affiliated organizations? Does the entity manufacture or commercialize any device, vaccine, procedure, drug or any other product associated with the research? If yes, are the goods and or services available commercially from other sources? Does the entity participate in deciding the direction of the research? is it reasonable to anticipate that the entity will or could be directly and signi?cantly affected by the design, conduct or reporting of the research activity? Will any of the research be conducted in the entity?s facilities? Will entity employees or consultants use any of facilities to conduct their portion of the research? Will any of the entity?s personnel work on the research? ?ll El El DIED DEE ED El DEICI Please Explain: Please Explain: Please Explain: Please indicate how many hours per week will be spent in the entity?s facilities Please Explain: Name of Entity#2 I Type of Entity Public Private For Profit Not for Profit DUDE Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 UL A?iliation (UL, ULF, individual holding relationship months ULRF, ULAA) Cl or Philanthropic Donation Consulting Ownership Employment (includes Chief Scienth?ic Officer) Stock or Stock Options or other ownership interests Executive Position (President, VP,etc) Board of Directors Training Service Grant Advisory Board Honorarium Entitlement to Deferred Compensation Payment for lectures or papers Royalties for inventions Sponsored Research Payment for product evaluation Research Supplies Gift Research Equipment Gift Research Equipment Loan DDUDD Other (describe): Activity (Check all that apply) Time Period Previous 12 Upcoming if yes, provide applicable months 12 months and or Award Animal Research Applied Research Bench Work Clinical Trial Human Subjects, Not Clinical Trial Preclinical Pilot Study Feasibility Study Marketing Study CME Educational Activity Activity Speaker?s Bureau Data Safety Monitoring Board Other (describe): BUDDIES DECIDED DECIDED is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? ls the entity contributing gift funds that are under your control or of direct benefit to your research or scholarly activity to of or one of its a?iliated organizations? Does the entity manufacture or commercialize any device, vaccine, procedure, drug or any other product associated with the research? if yes, are the goods and or services available commercially from other sources? Does the entity participate in deciding the direction of the research Is it reasonable to anticipate that the entity will or could be directly and significantly affected by the design, condUCt or reporting of the research activity? Will any of the research be conducted in the entity?s facilities? Will entity employees or consultants use any of facilities to conduct their portion of the research? Will any of the entity?s personnel work on the research 543 EDD Please Explain: Please Explain: Please Explain: Please indicate how many hours per week will be spent in the entity?s facilities Please Explain: Name of Entity#3 I Type of Entity Public Private For Profit Not for Profit DEED Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 UL A?iliation (UL, ULF, individual holding relationship months ULRF, UMA) Cl or Philanthropic Donation Consulting Ownership Employment {includes Chief Scientific Officer) Stock or Stock Options or other ownership interests Executive Position (President, VP,etc) Board of Directors Training Service Grant Advisory Board Honorarium Entitlement to Deferred Compensation Payment for lectures or papers Royalties for inventions Sponsored Research Payment for product evaluation Research Supplies Gift Research Equipment Gift Research Equipment Loan Other (describe): Activity {Check all that apply) Time Period Previous 12 Upcoming If yes, provide applicable months 12 months 18C and or Award Animal Research Applied Research Bench Work Clinical Trial Human Subjects, Not Clinical Trial Preclinical Pilot Study Feasibility Study Marketing Study CME Educational Activity Activity Speaker?s Bureau Data Safety Monitoring Board Other (describe): DECIDED ls the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? is the entity contributing gift funds that are under your control or of direct bene?t to your research or scholarly activity to of or one of its affiliated organizations? Does the entity manufacture or commercialize any device, vaccine, procedure, drug or any other product associated with the research? if yes, are the goods and or services available commercially from other sources? Does the entity participate in deciding the direCtion of the research? is it reasonable to anticipate that the entity will or could be directly and significantly affected by the design, conduct or reporting of the research activity? Will any of the research be conducted in the entity?s facilities? Will entity employees or consultants use any of facilities to conduct their portion of the research? Will any of the entity?s personnel work on the research DUB ED Cl El EDD EDD Please Explain: Please Explain: Please Explain: Please indicate how many hours per week will be spent in the entity?s facilities Please Explain: Name of Entity#4 Type of Entity Public Private For Profit Not for Profit DEED Relatianships (check all that apply) Approximate Value Previous 12 months Expected in next 12 UL A?iliation (UL, ULF, Individual holding relationship months ULRF, ULAA) Cl or Philanthropic Donation Consulting Ownership Employment (includes Chief Scientific Officer) Stock or Stock Options or other ownership interests Executive Position (President, VP,etc} Board of Directors Training Service Grant Advisory Board Honorarium Entitlement to Deferred Compensation Payment for lectures or papers Royalties for inventions Sponsored Research Payment for product evaluation Research Supplies Gift Research Equipment Gift Research Equipment Loan DEEDS Other (describe): Activity (Check all that apply) Time Period Previous 12 Upcoming if yes, provide applicable months 3 12 months and orAward Animal Research Applied Research Bench Work Clinical Trial Human Subjects, Not Clinical Trial Preclinical Pilot Study Feasibility Study Marketing Study CME Educational Activity Activity Speaker?s Bureau Data Safety Monitoring Board Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? is the entity contributing gift funds that are under your control or of direct bene?t to your research or scholarly activity to of or one of its a?iliated organizations? Does the entity manufacture or commercialize any device, vaccine, procedure, drug or any other product associated with the research? if yes, are the goods and or services available commercially from other sources? Does the entity participate in deciding the direction of the research? is it reasonable to anticipate that the entity will or could be directly and significantly affected by the design, conduct or reporting of the research activity? Will any of the research be conducted in the entity?s facilities? Will entity employees or consultants use any of facilities to conduct their portion of the research? Will any of the entity?s personnel work on the research Please Explain: Please Explain: Please Explain: Please indicate how many hours per week will be spent in the entity?s facilities Please Explain: C42. What gifts have you and/or your immediate family members received from an external entity that is engaged in research transactions with of or one of its affiliated organizations? Gifts {check all that apply) Approximate Value Previous 12 months Expected in next 12 months Entity providing Gift individual receiving gift Meals Travel or Lodging Meeting Conference Registrations Tickets to Entertainment Events Software Gift Cards Certificates Other (describe) C43. What proprietary interests do you and/or your immediate family members hold with the Entity that is engaged in research transactions with of of one of its affiliated organizations? Questions to be answered for each entity in which you or an immediate family member has a relationship) Name of Entity#1 Proprietary interest (check all that apply) Previous 12 months Expected in next 12 If yes, provide applicable individual holding relationship months and orAward Ci or Pending Provisional Patent issued Patent Licensing Agreement Option Material Transfer Agreement Trademark Copyright Trade Secret Invention Other (describe) No Yes is an entity in which you or an immediate family member hold a Entity holds a DEntity is DEntity holds a license, IE Entity holds a license, but the relationship currently have rights or negotiating rights? license from of negotiating a but of assigned the application, patent, license or license invention to me copyright did not arise from my employment at of if yes, is the entity providing any proprietary data, materials or VA equipment, as part of a licensing or sponsored research agreement? Are there any other of employees listed as inventors that also hold I: Please explain: equity in the entity? Name of Entity#2 Proprietary interest (check all that apply) Previous 12 months Expected in next 12 months if yes, provide applicable Individual holding relationship and/orAward Cl or Pending Provisional Patent issued Patent Licensing Agreement Option Material Transfer Agreement Trademark Copyright Trade Secret invention Other (describe) EMBEDDED is an entity in which you or an immediate family member hold a relationship currently have rights or negotiating rights? if yes, is the entity providing any proprietary data, materials or equipment, as part of a licensing or sponsored research agreement? No Yes Entity holds a license from of l. DEntity is negotiating a license Ell] Are there any other of 1. employees listed as inventors that also hold Please explain: equity in the entity? DEntity holds a license, but of assigned the invention to me Entity holds a license, but the application, patent, license or copyright did not arise from my employment at of Name of Entity#3 Proprietary Interest (check all that apply) Previous 12 months Expected in next 12 months if yes, provide applicable Individual holding relationship IBC and orAward Cl or Pending Provisional Patent issued Patent Licensing Agreement Option Material Transfer Agreement Trademark Copyright Trade Secret invention Other (describe) EMBEDDED Is an entity in which you or on immediate family member hold a relationship currently have rights or negotiating rights? if yes, is the entity providing any proprietary data, materials or equipment, as part of a licensing or sponsored research agreement? No Yes Entity holds a license from of DEntity is negotiating a license Are there any other of employees listed as inventors that also hold Please explain: equity in the entity? DEntity holds a license, but of assigned the invention to me Entity holds a license, but the application, patent, license or copyright did not arise from my employment at of Name of Entity#4 Proprietary Interest (check all that apply) Previous 12 months Expected in next 12 months if yes, provide applicable and or Award individual holding relationship or Pending Provisional Patent issued Patent Licensing Agreement Option Material Transfer Agreement Trademark Copyright Trade Secret in vention Other (describe) is an entity in which you or an immediate family member hold a relationship currently have rights or negotiating rights? If yes, is the entity providing any proprietary data, materials or equipment, as part of a licensing or sponsored research agreement? No Yes I: Entity holds a license from of l. DEntity is negotiating a license EJEI Are there any other of 1. employees listed as inventors that also hold I: Please explain: equity in the entity? DEntity holds a license, but of assigned the invention to me Entity holds a license, but the application, patent, license or copyright did not arise from my employment at of C.4.4. What direct payments are you and/or your immediate family members receiving in relation to your research? Direct Payments (check all that apply) Approximate Value Previous 12 months Expected in next 12 If yes, provide applicable months 13C and or Award Milestone Payments Incentive Payments Recruitment Bonuses Reimbursement for services above reasonable costs Other (describe) El C.4.5. What research projects in which you and/or your immediate family members have an external interest involve students, interns, residents, fellows, graduate students, or other trainees under your supervision or mentorship? (Questions to be answered for each project sponsored by an entity in which you or an immediate family member has a relationship) Project#1 I Provide applicable 1R8, CUC, ABC and or Award What is the nature of the relationship with the individual DStudent DResident DFeilow DTrainee Elintern DOther: Student, Resident, Fellow, Trainee, intern, Other (please specify) What entity is supporting the project? List an unbiased third party who can serve as a co-mentor for these individuals Are there any constraints or restrictions imposed on the No Yes Please Explain reporting or publication of the student trainee work? Project#2 Provide applicable and or Award What is the nature of the relationship with the individual [jStudent DResident DFellow EITrainee Dintem DOther: Student, Resident, Fellow, Trainee, intern, Other (please specify) What entity is supporting the project? List an unbiased third party who can serve as a co-mentorfor these individuals Are there any constraints or restrictions imposed on the No Yes Please Explain reporting or publication of the student trainee work? Project#3 1 Provide applicable and or Award What is the nature of the relationship with the individual [:IStudent DResident DFeliow EITrainee Ulntem DOther: Student, Resident, Fellow, Trainee, Intern, Other (please specify) What entity is supporting the project? List an unbiased third party who can serve as a co-mentor for these individuals Are there any constraints or restrictions imposed on the No El Yes Please Explain reporting or publication of the student trainee work? Project#4 What is the nature of the relationship with the individual Student, Resident, Fellow, Trainee, intern, Other (please specify) What entity is supporting the project? List an unbiased third party who can serve as a cosmentorfor these individuals Are there any constraints or restrictions imposed an the reporting or publication of the student trainee work? Provide applicable IRB, and orAward EIStudent BNO Yes DResident Please Explain DFellow El Trainee Dlntern Other: Project#5 What is the nature of the relationship with the individual Student, Resident, Fellow, Trainee, intern, Other (please specify) What entity is supporting the project? List an unbiased third party who can serve as a co?mentor for these individuals Are there any constraints or restrictions imposed on the reporting or publication of the student trainee work? 1 Provide applicable and or Award DStudent Diva Yes DResident Please Explain UFellow Trainee Elintern DOther: C4. 6. In what capacity do you and/or your immediate family members employ faculty, staff, students or trainees in an external entity that is engaged in research transactions with the of or one of its a?iliated organizations? Employment Relationships List all such of faculty, sta?, students and Individual holding relationship (check all that apply) trainees employed Ci or Employee full time Employee part time Employee - contract Advisor Consultant Other (describe): C4. 7. For what external or internal bodies do you and/or your immediate family members serve that has jurisdiction to award or distribute government funds committees of NIH, FDA, or other governmental agencies, private professional or regulatory body) where participation would reasonably appear to be influenced by the presence or existence of an external interest or relationship? List all such internal and external bodies within this Individual holding relationship category Cl or C.4.8. From which Entity do you and/or your immediate family members receive sponsored or directly reimbursed travel expenses? Name of Entity#1 I I Type of Entity Public Private For Profit Not for Profit DUDE Purpose of Trip (check all that apply) Duration DestinatiOn individual traveling investigator Meeting Training Consulting Lecture Advisory Board Data Safety Monitoring Board Speakers? Bureau Presentation Other (describe): Name of Entity#2 I Type of Entity Public Private For Pro?t Not for Profit DUDE Purpose of Trip (check all that apply) Duration Destination Individual traveling Investigator Meeting Training Consulting Lecture Advisory Board Data Safety Monitoring Board Speakers? Bureau Presentation Other (describe): Name of Entity#3 I Type of Entity Public Private For Profit Not for Pro?t EDD Purpose of Trip (check all that apply) Duration Destination Individual traveling investigator Meeting Training Consulting Lecture Advisory Board Data Safety Monitoring Board Speakers? Bureau Presentation Other (describe): Name of EntityM Type of Entity Public Private For Profit Not for Profit SEED Purpose of Trip (check all that apply) Duration Destination individual traveling Investigator Meeting Training Consulting Lecture Advisory Board Data Safety Monitoring Board Speakers? Bureau Presentation Other (describe): Name of Entity#5 Type of Entity Public Private For Profit Not for Profit DUDE Purpose of Trip {check all that apply) Duration Destination Individual traveling investigator Meeting Training Consulting Lecture Advisory Board Data Safety Monitoring Board Speakers? Bureau Presentation Other (describe): C.5.1. What relationship do you and/or your immediate family members hold with the external entity that engages in business, academic, clinical or research tr ansactions with the of or one Of its a?iliated organizations? (Questions to be answered for each entity in which you or an immediate family member has a relationship) Name of Entityiil Type of Entity Public Private For Profit Not for Profit EDXD Relationships (check all that apply) Approximate Value Previous 12 months Expected in next 12 UL Affiliation (UL, ULF, individual holding relationship months ULRF, ULAA) Cl or Philanthropic Donation Consulting Ownership Employment Stock or Stock Option Executive Position (President, VP,etc) Board of Directors Advisory Board Honorarium Entitlement to Deferred Compensation Equipment Gift Equipment Loan Other (describe): Ca-editor UofL Activity {Check all that apply) Time Period Previous 12 Upcoming months 12 months Conduct Research Assigning Research or Research resources Purchasing Accounts Receivable Contracting Personnel Facilities Use Vendor Selection and or Approval Clinical Care Academic Services Other (describe): Co-editor No Yes ls the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity serve as a vendor, research sponsor or maintain another relationship to the University of Louisville? What is the nature of the entity? Do you hold proprietary rights in the entity? Does the entity participate in deciding the direction of the administrative decisions at the University of Louisville? is it reasonable to anticipate that the entity will or could be directly and signi?cantly affected by administrative decisions at the University of Louisville? Name of Entity#2 I Type of Entity Public Private For Profit Not for Profit Relationships (check all that apply) DUDE Approximate Value Previous 12 months months Expected in next 12 ?Business >11 UL A?iliation (UL, ULF, mm? ULRF, ULAA) Please Explain: DSocial DProfessional DReligious Please Explain: Bookstore could decide not to carry and Textbook of Surgery of which i am a chapter author and co- editor. individual holding relationship Cl or Philanthropic Donation Consulting Ownership Employment Stock or Stock Option Executive Position (President, VP,etc) Board of Directors Advisory Board Honorarium Entitlement to Deferred Compensation Equipment Gift Equipment Loan Other (describe): Activity (Check all that apply) Time Period Conduct Research Assigning Research or Research resources Purchasing Accounts Receivable Contracting Personnel Facilities Use Vendor Selection and or Approval Clinical Care Academic Services Other (describe): is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity serve as a vendor, research sponsor or maintain another relationship to the University of Louisville? What is the nature of the entity? Do you hold proprietary rights in the entity? Previous 12 Upcoming months 12 months No Yes Please Explain: lZIBusiness DCivil [:ISocial DProfessionol DReligious Does the entity participate in deciding the direction of the administrative decisions at the University of Louisville? is it reasonable to anticipate that the entity will or could be directly and significantly affected by administrative decisions at the University of Louisville? Please Explain: . Name of Entity#3 Type of Entity Public Private For Profit Not for Profit Relationships (check all that apply) DUDE Approximate Value Previous 12 months Expected in next 12 UL A?iliation (UL, ULF, months ULRF, ULAA) individual holding relationship Ci or Philanthropic Donation Consulting Ownership Employment DUDE Stock or Stock Option Executive Position (President, VP,etc) Board of Directors Advisory Board Honorarium Entitlement to Deferred Compensation Equipment Gift Equipment Loan Other {describe}: Activity (Check all that apply) Conduct Research Assigning Research or Research resources Purchasing Accounts Receivable Contracting Personnel Facilities Use Vendor Selection and or Approval Clinical Care Academic Services Other (describe): Previous 12 Time Period Upcoming months 12 months is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate services, select goods or make referrals? Does the entity serve as a vendor, research sponsor or maintain another relationship to the University of Louisville? What is the nature of the entity? Do you hold proprietary rights in the entity? Does the entity participate in deciding the direction of the administrative decisions at the University of Louisville is it reasonable to anticipate that the entity will or could be directly and signi?cantly affected by administrative decisions at the University of Louisville? Name of Entity? Type of Entity Public No CIBusiness Yes [jcn? Please Explain: [:ISocial [:JProfessional Please Explain: CIReligious Private For Profit ?3 Not for Profit [3 Relationships {check all that apply) Approximate Value Previous 12 months Expected in next 12 UL Affiliation (UL, ULF, individual holding relationship months ULRF, ULAA) Cl or Philanthropic Donation Consulting Ownership Employment Stock or Stock Option Executive Position (President, VP, etc) Board of Directors Advisory Board Honorarium Entitlement to Deferred Compensation Equipment Gift Equipment Loan Other (describe): Activity (Check all that apply) Time Period Previous 12 Upcoming months 12 months Conduct Research Assigning Research or Research resources Purchasing Accounts Receivable Contracting Personnel Facilities Use Vendor Selection and or Approval Clinical Core Academic Services Other (describe): No Yes Is the entity providing or receiving goods, services or funds in an area that you supervise, select or evaluate [3 Please Explain: services, select goods or make referrals? Does the entity serve as a vendor, research sponsor or maintain another relationship to the University of Louisville? What is the nature of the entity? [:IBusiness DCivil DProfessional [:lReligious Do you hold proprietary rights in the entity? Does the entity participate in deciding the direction of the administrative decisions at the University of El Louisville? ls it reasonable to anticipate that the entity will or could be directly and significantly affected by administrative Please Explain: decisions at the University of Louisville? C.5.2. In what capacity do individuals under your direct supervision engage in business, academic, clinical or research transactions with an external entity in which you and/or your immediate family members hold a relationship or controlling interest? List all such direct reports individual holding relationship Cl or Russell W. Bessette, M.D. David L. Dunn, M. 0., Ph. D. Empmyee Signature Based [man the responses, the Con?ict 0f lntarest Of?ce may feuow up with yau for additio?ai infermatian t0 ensure compiiance with federai reguiatisns and er of palicies. I hereby that I have read and understand the Anagrams Panama. ENDNIDUAL CORFUCF or POLICY AME) Pmcsouaes AND Apeagssma msmunomr Coremcr or lemaesr POLECY AND Pamnunas and that the afaremantianed facts and situaticms indicate ail mama! interests arad Activities with regard ta my raids) at the Univers'rry of Lauisvi?e. [f I have mane, I have 56 indicated in the spaces provided. acknowiedge that i have a mn?nuing obligatian to ?le an updated farm within 33 days, if changes arise that may either give rise ta 3 new Externai Interest er Activity 01' the eiiminatisn of an Exterrzai rntenest 0r Activity previwaly disctosed. Signed this {?aw was. Emp?ayee Printed Name DammMD, Phi).