{"id":4482,"date":"2026-07-15T17:12:10","date_gmt":"2026-07-15T17:12:10","guid":{"rendered":"https:\/\/in.nau.edu\/research\/?page_id=4482"},"modified":"2026-07-27T00:17:22","modified_gmt":"2026-07-27T00:17:22","slug":"significant-financial-interest-sfi-disclosure-form","status":"publish","type":"page","link":"https:\/\/in.nau.edu\/research\/proposal-award-management\/proposal-development\/compliance-considerations\/significant-financial-interest-sfi-disclosure-form\/","title":{"rendered":"Significant financial interest (SFI) disclosure form"},"content":{"rendered":"<div class=\"nau-block nau-block-left-nav-top-bound\">\n    \t<button id=\"left-nav-toggle-btn\" onclick=\"toggleNav();\">\n\t\tON THIS PAGE \n\t\t<i id=\"chevron-icon\" class=\"fas fa-solid fa-chevron-down\"><\/i>\n\t<\/button>\n\t<div id=\"left-nav-menu-track\">\n\t\t<div id=\"left-nav-wrapper\">\n\t\t\t<div class=\"rfi-above-anchor-tags\">\n\t\t\t\t<div class=\"ri-container\">\n\t\t\t\t\t<a href=\"https:\/\/nau.edu\/admissions\/request-information\/\" id=\"request-info\" class=\"btn bg-true-blue left-nav-menu-bottom-button display-mobile\">Request info&nbsp;&nbsp;<\/a>\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t\t<div id=\"left-nav-menu\">\n\t\t\t\t<div class=\"menu-section menu-section-links\"><h6 class=\"hidden-mobile left-nav-list-header\">ON THIS PAGE<\/h6><ul class=\"left-nav-menu-list left-nav-automatic on-this-page\"><\/ul><div class=\"ri-container\"><a href=\"https:\/\/nau.edu\/admissions\/request-information\/\" id=\"request-info\" class=\"btn bg-true-blue left-nav-menu-bottom-button display-mobile\">Request info&nbsp;&nbsp;<\/a><\/div><\/div>\t\t\t\t\t\t\t\t<div class=\"menu-section backcolor\">\n\t\t\t\t\t<div class=\"header\">\n\t\t\t\t\t\tHOW CAN WE HELP?\t\t\t\t\t<\/div>\n\t\t\t\t\t<ul class=\"responsive-icons\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<li><a href=\"tel:928-523-4880\"><img decoding=\"async\" src=\"https:\/\/in.nau.edu\/wp-content\/themes\/nau-marketing-2021\/img\/icon-phone.svg\" alt=\"Telephone:\"> 928-523-4880<\/a>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t\t\t\t\t<li><a href=\"mailto:NAU-OSP@nau.edu\"><img decoding=\"async\" src=\"https:\/\/in.nau.edu\/wp-content\/themes\/nau-marketing-2021\/img\/icon-email.svg\" alt=\"Email:\"><span class=\"left-nav-email\"> NAU-OSP&#8203;@nau.edu <\/span><\/a><\/li>\n\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div>\n\n<section class=\"nau-block left-nav-section\"><header class=\"entry-header\"><div class=\"breadcrumb\"><ol class=\"breadcrumbs\"><li><a href=\"https:\/\/stage.in.nau.edu\">IN<\/a><span class=\"breadcrumb-chevron\" aria-hidden=\"true\">&gt;<\/span><\/li><li><a href=\"https:\/\/in.nau.edu\/research\">NAU Research<\/a><span class=\"breadcrumb-chevron\" aria-hidden=\"true\">&gt;<\/span><\/li><li class=\"current\">Pages<\/li><\/ol><\/div><h1 class=\"entry-title text-left \">Significant financial interest (SFI) disclosure form<\/h1><hr class=\"h1-hr  text-left \" role=\"none\"><\/header><!-- .entry-header --><\/section><!-- <section class=\"nau-block left-nav-section grid-md-12\">\n    <header class=\"entry-header\">\n        <h1 class=\"entry-title text-left \" tabindex=\"0\" id=\"h1-first\">Dummy H1<\/h1>\n        <hr class=\"h1-hr  text-left \" role=\"none\">\n    <\/header>\n<\/section> -->\n\n<section class=\"nau-block left-nav-section grid-md-12\">\n    <div class=\"page-content\">\n        \n\n<p class=\"wp-block-paragraph\">NAU is committed to promoting objectivity, openness, and transparency in research and ensuring institutional compliance with applicable federal regulations and non-federal agency guidelines. Accordingly, the Office of Sponsored Projects (OSP) requires all investigators (\u201cinvestigator\u201d means any individual who is responsible for the design, conduct, reporting of a sponsored project, or a proposal for such funding) to submit annually and prior to the submission of sponsored projects proposals a Significant Financial Interest (SFI) Disclosure Form Completion and submission of this form fulfills these disclosure and certification requirements. NAU\u2019s goal is to support Investigators in protecting the integrity of their research and ensuring the design, conduct, and reporting of sponsored projects activities will not be biased by an investigator\u2019s significant financial interests (SFIs). Federal and other applicable agency proposals\/applications will not be submitted until all required disclosure certifications have been completed by all investigators and submitted to OSP. Compliance with this requirement is a prerequisite for acceptance by NAU of a federal or other applicable agency sponsored grant or contract award.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Disclosure instructions<\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>All investigators must, at a minimum, complete and certify Section I of the disclosure form below. Sections II must also be completed if any answer to the questions in Section I.a regarding significant financial interests is \u201cyes\u201d, then complete and certify Section II.<\/li>\n\n\n\n<li>Submit the completed disclosure certification to the assigned Pre-Award Research Administrator in the OSP.<\/li>\n\n\n\n<li>If there is a material change in an Investigator\u2019s previously disclosed significant financial interests or FTRP participation, a revised disclosure certification must be completed and filed with OSP within thirty (30) days of the change.<\/li>\n<\/ol>\n\n\n\n<p class=\"wp-block-paragraph\">All disclosures will be reviewed and handled according to&nbsp;<a href=\"https:\/\/nau.edu\/university-policy-library\/conflict-of-interest-sponsored-projects\/\">NAU\u2019s Conflicts of Interest in Sponsored Projects Policy<\/a>. All NAU Investigators seeking external sponsored funding from a federal agency and other applicable agencies are required to complete this form before a proposal can be submitted. Questions concerning sponsored projects or research-related disclosures should be addressed to:&nbsp;<a href=\"https:\/\/directory.nau.edu\/?person=tc885\">Thomas Champagne,<\/a> Associate Vice President for Research.<\/p>\n\n\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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    <h2 class=\"gform_title\">Significant financial interest form &#8211; FCOI\/FTRP split<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_22'  action='\/research\/wp-json\/wp\/v2\/pages\/4482#gf_22' data-formid='22' novalidate>\n        <div id='gf_progressbar_wrapper_22' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_22_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_22' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_22_88\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_88'>X\/Twitter<\/label><div class='gfield_description' id='gfield_description_22_88'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_88' id='input_22_88' type='text' value='' autocomplete='new-password'\/><\/div><\/div><div id=\"field_22_1\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sponsored project information<\/h3><\/div><fieldset id=\"field_22_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_3'>\n                            \n                            <span id='input_22_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_22_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_3.3' id='input_22_3_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_22_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_22_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_3.6' id='input_22_3_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_22_4\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_4'>Department\/school<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_22_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_5\" class=\"gfield gfield--type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_5'>Sponsor<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_22_5' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_6\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_6'>Project\/program title<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_22_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_7\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Significant financial interests<\/h3><\/div><fieldset id=\"field_22_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you or your family member (includes investigator\u2019s immediate family; specifically dependent children, spouse, or domestic partner) hold a position of management, such as board member, director, officer, partner, trustee, employee or consultant with a sponsor, a vendor or (sub) contractor related to the proposed sponsored project activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_8'>\n\t\t\t<div class='gchoice gchoice_22_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Yes'  id='choice_22_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_8_0' id='label_22_8_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='No'  id='choice_22_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_8_1' id='label_22_8_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you or your family member have a significant financial interest (SFI) in a sponsor, company, vendor or (sub) contractor related to your proposed sponsored project activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_9'>\n\t\t\t<div class='gchoice gchoice_22_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_22_9_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_9_0' id='label_22_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_22_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_9_1' id='label_22_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_61\" class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><p style=\"font-size: 80%;font-style: italic\">Significant Financial Interest includes payments (including salary, consulting\nfees, honoraria and gifts) stock, stock options, and\/or any other ownership\ninterest valued at more than $5,000 or 5% ownership and\/or a Financial Interest\nthat:<\/p>\n<ul style=\"font-size: 80%\">\n<li>if with a publicly traded entity, the aggregate value of any salary or other\npayments for services received during the 12-month period preceding the\ndisclosure, and the value of any equity interest during the 12-month period\npreceding or as of the date of disclosure, exceeds $5,000; or<\/li>\n<li>if with a non-publicly traded entity, the aggregate value of any salary or other payments for services received during the 12-month period preceding the disclosure exceeds $5,000; or<\/li>\n<li>if with a non-publicly traded company, is an equity interest of any value, including venture or other capital financing, during the 12-month period preceding or as of the date of disclosure; or<\/li>\n<li>is income exceeding $5,000 related to intellectual property rights and interests not reimbursed through the Institution, or<\/li>\n<li>reimbursed travel related to your institutional responsibilities (teaching, research, academic advising, etc.,) excluding travel reimbursed by U.S. Federal, state or local governmental agencies, U.S. institutions of higher education, research institutes affiliated with institutions of higher education, academic teaching hospitals, and medical centers<\/li>\n<\/ul><\/div><fieldset id=\"field_22_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Could the value of your or your family\u2019s significant financial interest reasonably affect the outcome of the proposed sponsored research\/activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_17'>\n\t\t\t<div class='gchoice gchoice_22_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_22_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_17_0' id='label_22_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_22_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_17_1' id='label_22_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_67\" class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_67'>Number of significant financial interests<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_22_67'>If you selected &#8220;yes&#8221; for any of the questions above, please enter the number of significant financial interests<\/div><div class='ginput_container ginput_container_select'><select name='input_67' id='input_22_67' class='small gfield_select'  aria-describedby=\"gfield_description_22_67\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='One (1)' >One (1)<\/option><option value='Two (2)' >Two (2)<\/option><option value='Three (3)' >Three (3)<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_22_63' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_2' class='gform_page' data-js='page-field-id-63' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_22_2' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_22_31\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">1. Disclosure of significant financial interests<\/h3><div class='gsection_description' id='gfield_description_22_31'>Enter information on the significant financial interest. <\/div><\/div><fieldset id=\"field_22_32\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_32'>\n                            \n                            <span id='input_22_32_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_22_32_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_32.3' id='input_22_32_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_22_32_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_22_32_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_32.6' id='input_22_32_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_22_36\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_36'>Name of organization in which you have (or your family has) a significant financial interest<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_22_36' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_33\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of significant financial interest with the organization\/individual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_33'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_33'><div class='gchoice gchoice_22_33_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.1' type='checkbox'  value='Consultant'  id='choice_22_33_1'   aria-describedby=\"gfield_description_22_33\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_1' id='label_22_33_1' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_33_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.2' type='checkbox'  value='Employee'  id='choice_22_33_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_2' id='label_22_33_2' class='gform-field-label gform-field-label--type-inline'>Employee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_33_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.3' type='checkbox'  value='Equity interest'  id='choice_22_33_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_3' id='label_22_33_3' class='gform-field-label gform-field-label--type-inline'>Equity interest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_33_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.4' type='checkbox'  value='Recipient of honoraria'  id='choice_22_33_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_4' id='label_22_33_4' class='gform-field-label gform-field-label--type-inline'>Recipient of honoraria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_33_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.5' type='checkbox'  value='Recipient of royalties'  id='choice_22_33_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_5' id='label_22_33_5' class='gform-field-label gform-field-label--type-inline'>Recipient of royalties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_33_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_33.6' type='checkbox'  value='Other'  id='choice_22_33_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_33_6' id='label_22_33_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_34\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_34'>If &quot;Other,&quot; please describe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_22_34' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The significant financial interest is between the organization and &#8230;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_35'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_35'><div class='gchoice gchoice_22_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Self'  id='choice_22_35_1'   aria-describedby=\"gfield_description_22_35\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_35_1' id='label_22_35_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Family member'  id='choice_22_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_35_2' id='label_22_35_2' class='gform-field-label gform-field-label--type-inline'>Family member<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you received in the last 12 months, or do you expect to receive in the next 12 months, payments for salary, director&#039;s fees, consulting, honoraria, royalties, or any other payments that when aggregated with payments from this organization to your spouse, domestic partner, and\/or dependent child will exceed $5,000?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_37'>\n\t\t\t<div class='gchoice gchoice_22_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_22_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_37_0' id='label_22_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_22_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_37_1' id='label_22_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you or your family member had in the last 12 months or do you anticipate having in the next 12 months, stock, stock options, other equity interests, or venture or other capital financing in the organization which, when aggregated have a fair market value exceeding $5,000 or have or will have an ownership interest of 5% or more in the organization?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_38'>\n\t\t\t<div class='gchoice gchoice_22_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Yes'  id='choice_22_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_38_0' id='label_22_38_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='No'  id='choice_22_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_38_1' id='label_22_38_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_39\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_39'>What relationship, if any, is there between the business or activities of the organization and your current or planned areas of research or proposed sponsored activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_22_39' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_22_68' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_22_68' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_3' class='gform_page' data-js='page-field-id-68' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_22_3' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_22_87\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">2. Disclosure of significant financial interests<\/h3><div class='gsection_description' id='gfield_description_22_87'>Enter information on the <strong>second <\/strong>significant financial interest. <\/div><\/div><fieldset id=\"field_22_86\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_86'>\n                            \n                            <span id='input_22_86_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_22_86_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_86.3' id='input_22_86_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_22_86_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_22_86_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_86.6' id='input_22_86_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_22_85\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_85'>Name of organization in which you have (or your family has) a significant financial interest<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_22_85' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_84\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of significant financial interest with the organization\/individual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_84'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_84'><div class='gchoice gchoice_22_84_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.1' type='checkbox'  value='Consultant'  id='choice_22_84_1'   aria-describedby=\"gfield_description_22_84\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_1' id='label_22_84_1' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_84_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.2' type='checkbox'  value='Employee'  id='choice_22_84_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_2' id='label_22_84_2' class='gform-field-label gform-field-label--type-inline'>Employee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_84_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.3' type='checkbox'  value='Equity interest'  id='choice_22_84_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_3' id='label_22_84_3' class='gform-field-label gform-field-label--type-inline'>Equity interest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_84_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.4' type='checkbox'  value='Recipient of honoraria'  id='choice_22_84_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_4' id='label_22_84_4' class='gform-field-label gform-field-label--type-inline'>Recipient of honoraria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_84_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.5' type='checkbox'  value='Recipient of royalties'  id='choice_22_84_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_5' id='label_22_84_5' class='gform-field-label gform-field-label--type-inline'>Recipient of royalties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_84_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_84.6' type='checkbox'  value='Other'  id='choice_22_84_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_84_6' id='label_22_84_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_83\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_83'>If &quot;Other,&quot; please describe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_22_83' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_82\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The significant financial interest is between the organization and &#8230;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_82'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_82'><div class='gchoice gchoice_22_82_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.1' type='checkbox'  value='Self'  id='choice_22_82_1'   aria-describedby=\"gfield_description_22_82\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_82_1' id='label_22_82_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_82_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_82.2' type='checkbox'  value='Family member'  id='choice_22_82_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_82_2' id='label_22_82_2' class='gform-field-label gform-field-label--type-inline'>Family member<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_81\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you received in the last 12 months, or do you expect to receive in the next 12 months, payments for salary, director&#039;s fees, consulting, honoraria, royalties, or any other payments that when aggregated with payments from this organization to your spouse, domestic partner, and\/or dependent child will exceed $5,000?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_81'>\n\t\t\t<div class='gchoice gchoice_22_81_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='Yes'  id='choice_22_81_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_81_0' id='label_22_81_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_81_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_81' type='radio' value='No'  id='choice_22_81_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_81_1' id='label_22_81_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you or your family member had in the last 12 months or do you anticipate having in the next 12 months, stock, stock options, other equity interests, or venture or other capital financing in the organization which, when aggregated have a fair market value exceeding $5,000 or have or will have an ownership interest of 5% or more in the organization?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_80'>\n\t\t\t<div class='gchoice gchoice_22_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Yes'  id='choice_22_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_80_0' id='label_22_80_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='No'  id='choice_22_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_80_1' id='label_22_80_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_79\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_79'>What relationship, if any, is there between the business or activities of the organization and your current or planned areas of research or proposed sponsored activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_22_79' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_22_78' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_22_78' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_4' class='gform_page' data-js='page-field-id-78' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_22_4' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_22_77\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">3. Disclosure of significant financial interests<\/h3><div class='gsection_description' id='gfield_description_22_77'>Enter information on the <strong>third<\/strong> significant financial interest. <\/div><\/div><fieldset id=\"field_22_76\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_76'>\n                            \n                            <span id='input_22_76_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_22_76_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_76.3' id='input_22_76_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_22_76_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_22_76_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_76.6' id='input_22_76_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_22_75\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_75'>Name of organization in which you have (or your family has) a significant financial interest<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_22_75' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of significant financial interest with the organization\/individual<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_74'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_74'><div class='gchoice gchoice_22_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Consultant'  id='choice_22_74_1'   aria-describedby=\"gfield_description_22_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_1' id='label_22_74_1' class='gform-field-label gform-field-label--type-inline'>Consultant<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Employee'  id='choice_22_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_2' id='label_22_74_2' class='gform-field-label gform-field-label--type-inline'>Employee<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Equity interest'  id='choice_22_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_3' id='label_22_74_3' class='gform-field-label gform-field-label--type-inline'>Equity interest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_74_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.4' type='checkbox'  value='Recipient of honoraria'  id='choice_22_74_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_4' id='label_22_74_4' class='gform-field-label gform-field-label--type-inline'>Recipient of honoraria<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_74_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.5' type='checkbox'  value='Recipient of royalties'  id='choice_22_74_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_5' id='label_22_74_5' class='gform-field-label gform-field-label--type-inline'>Recipient of royalties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_74_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.6' type='checkbox'  value='Other'  id='choice_22_74_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_74_6' id='label_22_74_6' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_73\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_73'>If &quot;Other,&quot; please describe<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_22_73' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_72\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >The significant financial interest is between the organization and &#8230;<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_22_72'>Check all that apply<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_22_72'><div class='gchoice gchoice_22_72_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.1' type='checkbox'  value='Self'  id='choice_22_72_1'   aria-describedby=\"gfield_description_22_72\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_22_72_1' id='label_22_72_1' class='gform-field-label gform-field-label--type-inline'>Self<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_22_72_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_72.2' type='checkbox'  value='Family member'  id='choice_22_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_22_72_2' id='label_22_72_2' class='gform-field-label gform-field-label--type-inline'>Family member<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you received in the last 12 months, or do you expect to receive in the next 12 months, payments for salary, director&#039;s fees, consulting, honoraria, royalties, or any other payments that when aggregated with payments from this organization to your spouse, domestic partner, and\/or dependent child will exceed $5,000?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_71'>\n\t\t\t<div class='gchoice gchoice_22_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_22_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_71_0' id='label_22_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_22_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_71_1' id='label_22_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_70\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you or your family member had in the last 12 months or do you anticipate having in the next 12 months, stock, stock options, other equity interests, or venture or other capital financing in the organization which, when aggregated have a fair market value exceeding $5,000 or have or will have an ownership interest of 5% or more in the organization?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_70'>\n\t\t\t<div class='gchoice gchoice_22_70_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='Yes'  id='choice_22_70_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_70_0' id='label_22_70_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_70_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_70' type='radio' value='No'  id='choice_22_70_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_22_70_1' id='label_22_70_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_69\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_22_69'>What relationship, if any, is there between the business or activities of the organization and your current or planned areas of research or proposed sponsored activity?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_22_69' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_22_65' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_22_65' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_5' class='gform_page' data-js='page-field-id-65' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_22_5' class='gform_fields top_label form_sublabel_above description_above validation_below'><div id=\"field_22_40\" class=\"gfield gfield--type-section gsection field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Investigator Certification<\/h3><\/div><fieldset id=\"field_22_41\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_41'>\n                            \n                            <span id='input_22_41_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_22_41_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_41.3' id='input_22_41_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            \n                            <span id='input_22_41_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_22_41_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_41.6' id='input_22_41_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_42\" class=\"gfield gfield--type-date gfield--input-type-datefield gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_22_42' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_22_42_1_container'>\n                                            <label for='input_22_42_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                            <input type='number' maxlength='2' name='input_42[]' id='input_22_42_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_22_42_2_container'>\n                                            <label for='input_22_42_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                            <input type='number' maxlength='2' name='input_42[]' id='input_22_42_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_22_42_3_container'>\n                                            <label for='input_22_42_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                            <input type='number' maxlength='4' name='input_42[]' id='input_22_42_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2027' step='1'\/>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_22_64\" class=\"gfield gfield--type-consent gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Investigator Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_22_64_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_22_64\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_22_64_1' >I agree to the terms below<\/label><input type='hidden' name='input_64.2' value='I agree to the terms below' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_22_64' tabindex='0'>I have read and understand <a 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