Please check the box that best describes your project (please see definitions below):
(Science and Engineering Research and Development: On) Unchecked 


Science and Engineering Research and Development
(undefined) 
or
(Non-science and Engineering Research and Business: On) Unchecked 
Non-science and Engineering Research and Business
(undefined) 
(undefined) 


 Basic
(undefined) 
Education 
(undefined) 


 Applied
(undefined) 
Business 

 Development Other 

 

Basic Research undertaken primarily to acquire new knowledge without any particular application or use in mind. 

Applied Research conducted to gain the knowledge or understanding to meet a specific, recognized need. 

Development The systematic use of the knowledge directed toward the production of useful materials, devices, process, etc. 

Education Work aimed at improving or expanding the course taught at Millersville University 

Business Work that contributing primarily to economic development 

Other Work that does not easily fit within any of the other categories, such as work subcontracted to a city 

Will this project result in assignable intellectual property rights? (Assignable intellectual property may results in patents or 
commercializable technology. See http://www.millersville.edu/development/grants/technology.php
(commercializable technology. See http://www.millersville.edu/development/grants/technology.php for more information: Yes_3) Unchecked 
for more information) 

 Yes
(If yes, list your IRB Protocol Number) 
(commercializable technology. See http://www.millersville.edu/development/grants/technology.php for more information: No_3) Unchecked 
No 

Will this project involve human subjects? (If you are unsure what constitutes the use of human subjects, contact the OFGS)
(Will this project involve human subjects? (If you are unsure what constitutes the use of human subjects, contact the OFGS: Yes_4) Unchecked 


 Yes
(Will this project involve human subjects? (If you are unsure what constitutes the use of human subjects, contact the OFGS: No_4) Checked 
No 

If yes, list your IRB Protocol Number: . Please attach a copy of your IRB Request for Protocol form, 
IRB number or IRB approval letter to this packet. For more information see http://www.millersville.edu/development/grants/ 

 

Signature indicates general approval of technical merit, allocation of space/resources, instructional reassignment, salary 
arrangements, fiscal budgeting, administrative obligations, and cognizance of any risks. Signature also verifies that all costs including 
employee benefits and indirect costs are provided for and that proposed matching funds are available and can be satisfactorily 
documented. 

 Name (Print) Signature (required)
(text) 
Date 

Originator/Prin. Investigator
(undefined) Richard Hell 


Department Chairperson
(undefined) Joseph Strummer 
(text) 


Dean
(undefined) Dr. John Doe 
(text) 


Director, Fdn & Gov�t Support Dr. Ren� Mu�oz 
(text) 


Chair, IRB Committee Dr. Victor S. DeSantis 
(text) 


Director, Accounting Mr. Teh Krajan 
(text) 


Assoc. V.P., Finance & Admin. Mr. Kenneth E. Dearstyne, Jr.
(text) 


V.P., Information Technology Mr. Chip German 
(text) 


Provost Dr. Vilas Prabhu 
(text) 


President Dr. Francine McNairy 
(text) 



 

Millersville University 

Financial Disclosure/Conflict of Interest 

 

Federal regulations require institutions to have policies and procedures in place that ensure that Investigators disclose any 
significant financial interest that may present an actual or potential conflict of interest in relationship to externally sponsored 
projects. Such disclosures must be made prior to the submission of a proposal for funding*, and institutions must develop 
specific mechanisms by which conflicts of interest will be satisfactorily managed, reduced, or eliminated prior to the expenditure 
of any funds on an award. 

What must be disclosed? 

Each Investigator shall disclose all significant financial interests: 

1. That would reasonably appear to be affected by the research, educational, or service activities funded, or 
proposed for funding, by an external sponsor; or 
2. In entities whose financial interests would reasonably appear to be affected by such activities. 


"Significant financial interests" means anything of monetary value, including, but not limited to, salary or other payments for services 
(e.g., consulting fees or honoraria); equity interests (e.g., stocks, stock options, or other ownership interests); and intellectual 
property rights (e.g., patents, copyrights, and royalties from such rights). The term does not include: 

1. Salary, royalties, or other remuneration from Millersville University; 
2. Income from seminars, lectures, or teaching engagements sponsored by public or nonprofit entities; 
3. Income from service on advisory committees or review panels for public or nonprofit entities; or 
4. An equity interest that when aggregated for the Investigator and the Investigator�s spouse and dependent children, 
meets both of the following tests: does not exceed $10,000 in value as determined through reference to public prices or 
other reasonable measures of fair market value, or, constitute more than a five percent ownership interest in any 
single entity; or 
5. Salary, royalties or other payments that when aggregated for the Investigator and the Investigator�s spouse and 
dependent children over the next twelve months, are not expected to exceed $10,000. 


Disclosure Procedures: 

1. In accordance with Federal regulations, a complete disclosure must be made by Investigator(s) prior to submission 
of the proposal. 
2. If a PI holds a significant financial interest in a sponsor, they must disclose this interest to the University by utilizing 
the attached form. The completed forms must be signed by the investigator and returned with explanations to 
the Dean of Research, who will review and maintain these files. All information will be kept confidential. 
3. Resolutions to conflicts of interest will be incorporated into a Memorandum of Understanding between the 
Investigator(s) and the University [signed by Investigator(s), and the Dean prior to expenditure of any award funds. 


 

 

 

 

 

 

 

 

 


Millersville Financial 

Conflict of Interest Questionnaire 

 

All investigators must respond to the following questions by checking the �Yes� or �No� boxes. If you answer yes to any of the 
following questions, please complete the attached Financial Disclosure Form. 

 

1. Are you, your co-PIs or your immediate family members, major officers of, or employees with a managerial role, or have a 
significant financial interest in the proposed sponsors?* (See Conflict of Interests Policy for further explanation. The full policy 
can be found at: http://www.millersville.edu/development/grant/policies.php). 


 

 NO YES 

 

2. Do you or your co-PIs have a consulting relationship with this sponsor? 


 

 NO YES 

 

3. Has this sponsor provided you or your department/unit with any gifts or funds? 


 

 NO YES 

 

4. Do you or your co-PIs have any relationships, commitments including assignments of Intellectual Property Rights), activities 
(including uncompensated activities) or financial/fiduciary interests that present potential or apparent conflict of interests or 
commitments with the project? 


 

 NO YES 

 

Signed ___________________________________________________________ Date 


Millersville University 

Financial Interest Disclosure Form 

 

Name Dept. School _______________________ 

Project Title: 

Funding Agency: 

I am disclosing the following significant financial interests (check one) and attaching supporting documentation (in an 
envelope marked confidential) that identifies the business enterprise or entity involved, the nature and amount of the 
interest, and suggestions for managing this potential conflict of interest. 

 Salary or other payment for services (e.g., consulting fees or honoraria). 

 Equity interests (e.g., stocks, stock options, or other ownership interests). 

 Intellectual property rights (e.g., patents, copyrights, and royalties from such rights). 

 Other significant financial interest of the Investigator that possibly could affect or be perceived to 
affect the results of the research, educational, or service activities funded or proposed for funding. 

Further I agree: 

� To update this disclosure during the period of the award as new reportable significant financial interests 
materialize. 
� To cooperate in the development of a Memorandum of Understanding (MOU) that constitutes a conflict of 
interest "resolution plan." 
� To comply with any conditions or restrictions imposed by the University to manage, reduce, or eliminate 
actual or potential conflicts of interest or forfeit the award. 
� To have a fully-executed MOU in place prior to making any expenditures of sponsored project funds. 


 

Signed: 

Signed Date 

I have reviewed the significant financial interest disclosure and believe that it will be possible to develop and execute, prior to 
expenditure of award funds, an MOU to manage, reduce, or eliminate any actual or potential conflict of interest; and, 
therefore, I recommend that that proposal be submitted to the agency at this time. 

 

Dean of Graduate Studies and Research: 

Signed Date 

School Dean: 

Signed Date