DocuSign Envelope ID: 

700-U

CALIFORNIA
FORM

 

STATEMENT OF ECONOMIC INTERESTS

Date Received
Campus Use Only

 

 

FAIR POLITICAL PRACTICES COMMISSION FOR
PRINCIPAL INVESTIGATORS 
ampus:

PI . . . A Public Document

ease type or print in ink. ID No:

NAME (LAST) (FIRST) (MIDDLE) TELEPHONE NUMBER
Murphy Kevin Timothy 619 804-3359
ACADEMIC UNIT OR DEPARTMENT MAIL CODE E-MAIL ADDRESS
Radiation Medicine Applied Sciences 0832 kevinmurphy@ucsd.edu

 

TITLE OF RESEARCH PROJECT
IRB #181330 180373

 

 

1. Information Regarding Funding Entity

(Use a separate Form 700-U for each funding entity.)
Name of Entity:
MindSet
Address of Entity:
16918 Dove Canyon Road, suite 102, SD CA 92127

Principal Business of Entity:

 

 

Outpatient clinic for treatment

 

Amount of Funding: 0

 

Estimated Actual El

 

 

 

2. Type of Statement (Check at least one box)
Initial (for new funding)
Date of initial funding: 

Interim (for renewed funding)
Funding was renewed on: 

 

 

 

3. Filer Information

A. Are you a director, officer, partner, trustee, consultant,
employee, or do you hold a position of management in
the entity listed in Part 1? No Yes

Title: owner of clinic, and president of MindSet

 

B. Do you, your spouse or registered domestic partner, or
your dependent children have an investment of $2,000
or more in the entity listed in Part 1 above?

No Yes value is:

$10,001 - $100,000
Exceeds $1,000,000

[1 $2,000 - $10,000
$100,001 - $1,000,000

Date Disposed: 44?, if applicable

C. Have you received income of $500 or more from the
entity listed in Part 1 during the reporting period?
No Yes amount is:

$500 - $1,000
$10,001 - $100,000

Was this income received through your spouse or
registered domestic partner? No I: Yes

$1,001 - $10,000
Exceeds $100,000

 

3. Filer Information - Cont.

D. Have you received loans from the entity in Part 1 for which
the balance exceeded $500 during the reporting period?
No Yes highest balance:

$500 - $1,000 $1,001 - $10,000
$10,001 - $100,000 Exceeded $100,000

If you checked "yes," was the loan:
Secured Unsecured Interest rate: 

Was the loan entirely repaid within the last 12 months?

I: No Yes

E. Have you received gifts from the entity listed in Part 1
within the last 12 months valued at $50 or more?

 

 

No Yes describe below.
Description:
Value: Date Received: I

F. Has the entity in Part 1 paid for your travel during the

reporting period? No Yes describe below.
Type of Payment: (check one) Gift Income
Amt: date(s): 

(If gift)

Description and, if Gift, Travel Destination:

 

 

 

 

 

 

4. Verification

have used all reasonable diligence in preparing this statement.
I have reviewed this statement and to the best of my knowledge
the information contained herein and in any attached schedules
is true and complete. I certify under penalty of perjury under the
laws of the State of California that the foregoing is true and correct.

 

3/11/2019
Date Signed
(month, day, year)
l?nml-?Huueul 
Signature I I mmIIl 1! eri 

 

(File the gfjg?r?pm?ig?q?l ,statement with your university.)

 

 

The Form is for university use only.

This statement is a public record under Gov. Code Section 81008(a).

FPPC Form 700-U (2018/2019)
FPPC Advice Email: 
FPPC Toll-Free Helpline: 866/275-3772 

 

DocuSign Envelope ID: 



 

STATEMENT OF ECONOMIC INTERESTS

Date Received
Campus Use Only

 

FAIR POLITICAL PRACTICES COMMISSION FOR
PRINCIPAL INVESTIGATORS 
. ampus:
PI . . . A Public Document
ease type or print In Ink. ID No:
NAME (LAST) (FIRST) (MIDDLE) TELEPHONE NUMBER
Murphy Kevin Timothy 619 )804-3359

 

ACADEMIC UNIT OR DEPARTMENT
Radiation Medicine Applied Sciences

MAIL CODE

ADDRESS
kevinmurphy@ucsd.edu

 

TITLE OF RESEARCH PROJECT

IRB 181330 180373 PeakLogic will provide an automated software recommendation for both protocols

 

 

1. Information Regarding Funding Entity

(Use a separate Form 700-U for each funding entity.)
Name of Entity:
PeakLogic Inc.

 

Address of Entity:
16918 Dove Canyon Road, suite 206, SD CA 92127

 

Principal Business of Entity:

Software development company for research

 

 

Amount of Funding: 0

Estimated Actual 

 

 

2. Type of Statement (Check at least one box)
Initial (for new funding)
Date of initial funding: 

Interim (for renewed funding)
Funding was renewed on: 

 

 

 

3. Filer Information

the entity listed in Part 1? No Yes
Title: CEO. owner of company

A. Are you a director, officer, partner, trustee, consultant,
employee, or do you hold a position of management in

 

or more in the entity listed in Part 1 above?
No Yes value is:

$10,001 - $100,000
Exceeds $1,000,000

[3 $2,000 - $10,000
$100,001 - $1,000,000

Date Disposed: if applicable

C. Have you received income of $500 or more from the
entity listed in Part 1 during the reporting period?
No Yes amount is:

$500 - $1,000
$10,001 - $100,000

Was this income received through your spouse or
registered domestic partner? No Yes

$1,001 - $10,000
Exceeds $100,000

 

B. Do you, your spouse or registered domestic partner, or
your dependent children have an investment of $2,000

 

3. Filer Information - Cont.

D. Have you received loans from the entity in Part 1 for which
the balance exceeded $500 during the reporting period?
No Yes highest balance:

$500 - $1,000 $1,001 - $10,000
[3 $10,001 - $100,000 Exceeded $100,000

If you checked ?yes,? was the loan:
Secured Unsecured Interest rate: 

Was the loan entirely repaid within the last 12 months?

[3 No Yes

E. Have you received gifts from the entity listed in Part 1
within the last 12 months valued at $50 or more?

 

 

No Yes describe below.
Description:
Value: Date Received: 

F. Has the entity in Part 1 paid for your travel during the
reporting period? No Yes describe below.

Type of Payment: (check one) El Gift Income

Amt: $35992). date(s): 

(if gift)

Description and, if Gift, Travel Destination:

 

 

 

 

4. Verification

I have used all reasonable diligence in preparing this statement.
I have reviewed this statement and to the best of my knowledge
the information contained herein and in any attached schedules
is true and complete. I certify under penalty of perjury under the
laws of the State of California that the foregoing is true and correct.

3/11/2019
Date Signed

 

(month, day, year)

Iq-

I,

Signature 
(FileIthe cgjginauyusigpeg[statement with your university.)

 

 

 

The Form 700-U is for university use only.

This statement is a public record under Gov. Code Section 81008(a).

FPPC Form 700-U (2018/2019)
FPPC Advice Email: advice@fppc.ca.gov
FPPC Toll?Free Helpline: 866/275-3772