ࡱ> gkfy B)bjbjBB 4^ ~_ ~_ !5N N 8,Dp6:NNN5555555$O8;P5NNNNN545###NF5#N5##2|T40X35506j3U;.U;$T4U;T4,NN#NNNNN55NNN6NNNNU;NNNNNNNNNN X : DEPARTMENTAL LETTERHEAD University of Texas at San Antonio Management Plan for Conflicts of Interests/Conflicts of Commitment Please note: UTS 180 (non-research) management only. I. General Information Name of Employee (Managed Individual)  Family Member, if relevant:  Department(s):  Building/Room Number:  Campus Mail Route Number:  Phone Number/Campus Extension:  Fax Number  Email Address:  List All UTSA Appointments   Name of Organization with Conflicting Interest (Entity): Identify Conflicting Activity (Conflicted Activity)Number of Hours Conflicting with UTSA Time: Per: (Week (Month (YearCompensation (per year) or Ownership Interest in Entity:  II. Description of the Conflict of Interest/Conflict of Commitment [Insert a brief description of the conflict, other than the information listed above] III. Plan for Managing the Conflict Please Note: The following is a list of common conflicts that may arise and can be used if applicable to the employees situation. It is not necessary to include those which are not relevant. The Managed Individual agrees to the following in order to manage this Conflict: Limit the activity to purely non-UTSA time by using vacation time, nights and weekends, or, for faculty only, using the [###] days per year allotted for scholarly activity. Abstain from all fiduciary responsibilities, including but not limited to voting activities, relating to the Entitys interactions with UTSA or the University of Texas at San Antonio. Divest himself/herself of all fiduciary responsibilities to the Entity. Divest himself/herself of all financial interests in the Entity. Terminate all relationships with the Entity. Abstain from using UTSA equipment, facilities, services, or personnel relating to the above-described activity. Avoid using the UTSA name or logo without express permission from UTSA on each and every occasion of use. Abstain from participating in negotiations between UTSA and the Entity, except as UTSA directs. Abstain from serving on the Entitys board of directors. Abstain from serving as an officer of the Entity. Abstain from disclosing UTSAs confidential information to the Entity. Never, under any circumstances, channel UTSA discoveries to the Entity. Abstain from receiving UTSA grant support from companies that the Managed Individual founded or co-founded. Make no decisions and take no action in your capacity as an employee of UTSA which could reasonably affect Entity. Make no decisions and take no action when acting on behalf of Entity which could reasonably affect UTSA. Dominance relationships: You will need to recuse yourself from all dominance relationships with XXXXX during this period. Such relationships would include influencing promotions, tenure decisions, performance evaluations, space assignments, resource allocations, and salary increases. Supervisory recusal: You will need to recuse yourself from supervising list specific individuals who are involved with the name the project/study which is related to ENTITY. [USE in concrete situations; this requires monitoring.] Public disclosure: You are required to provide disclosure as to the existence of your corporate/equity/IP relationship in all publications, presentations, and grant applications involving research related to ENTITY, its products and/or intellectual property. You should also disclose your ENTITY relationship if you are discussing direct competitors of ENTITY products. You may be required to provide example disclosures as a part of the continued monitoring and audit processes. Public disclosure: (educational grant) You are required to provide disclosure as to the existence of your XXXX gift in all publications, presentations, grant applications and possibly consent documents supported by the XXXX educational grant. You may be required to provide sample disclosures as a part of the continued monitoring and audit processes. Public disclosure: (GIFT) You are required to provide disclosure as to the existence of your ENTITY gift in all publications, presentations, grant applications and possibly consent documents involving research with ENTITY, its products and/or intellectual property. You may be required to provide sample disclosures as a part of the continued monitoring and audit processes. Disclosure of Intellectual Property (IP): You will need to provide disclosure of the existence of your IP rights (including royalties) in all publications, presentations, informed consent documents (All PIs and any Inv >25K, IP, or private equity), consulting activities, and grant applications involving this research or other ENTITY products. Students/Trainees/Investigators: (to be used in cases of IP/Equity/Royalties) It is your obligation to notify all students/trainees/investigators on your ENTITY related projects of your relationship with ENTITY. All students/trainees/investigators are required to disclose your relationship with ENTITY in all publications, presentations, consulting activities, and grant applications involving the related research. You must also make your students/trainees aware that they may contact the Research Integrity Office regarding any conflict of interest issues. Departmental Approval: For the purchase of any products for whose sales Entity will receive financial consideration, as well as all other products manufactured by Entity, you will need final approval for those purchases from your Chair or Dean. Procurement Approval: To ensure the appropriate conflict of interest safeguards are in place, you are required to notify UTSA Procurement Services of your Entity relationship when you are involved in purchasing decisions related to Entity products, either those you invented or other products manufactured by Entity. Recusal: You are not permitted to be involved with any purchasing decisions related to products manufactured by ENTITY. If requested, you may provide information to UTSA Procurement Services, but you may not be involved in the final decision-making process or negotiations regarding the actual purchasing of equipment or materials made or sold by ENTITY. Procurement Services (remove unless Private Equity) will be notified that you have been issued a management plan and will have access to the plan. Recusal: You are not permitted to be involved with any purchasing decisions related to products manufactured by ENTITY. If requested, you may provide information and advice to UTSA Procurement Services, but you may not be involved in the final decision-making process or negotiations regarding the actual purchasing of equipment or materials made or sold by ENTITY. Procurement Services (remove unless Private Equity) will be notified that you have been issued a management plan and will have access to the plan. Should this Entity become a sponsor of your research or your research become related to the Entity or its products, you must update your reporting form and contact RIO prior to the commencement of research. Procurement Approval: (Special Circumstances) Recognizing that Entity may at times be the best available source to perform certain experimental tests related to your research, it is possible to purchase services from Entity under certain restrictions. In particular, the purchase of products or services from Entity will require the review and documentation of purchase requests by a non-conflicted faculty member and procurement services. This procurement procedure must be included in grant submissions related to this Entity. IV. Term This management plan shall be in effect for the entire duration of the existing conflict. If at any time the Managed Individual feels that the conflict no longer exists, they have the right to request a review of this management plan by the [appropriate official or committee]. V. Public Display of Information In accordance with Institution Policy any managed conflict must be reported publicly on a website maintained by UT System. Only the name of the Managed Individual, the nature and extent of the activity, and the compensation will be reported. The compensation will only be reported if it is over $5,000, and information regarding family members will never be reported. VI. Approved and Adopted __________________________________ __________________ Name Date List all signatories per Institution Policy      PAGE \* MERGEFORMAT 1  -;<      * + , - . D E F G H ʽ|xtxxxxpxpph`h+3hg h/5hh@h/5 hh@h/h/hh0'hiL5CJaJh0'h0'5CJaJh0'5CJaJhVh'3h'35B*phh'35B*ph hC|5 hV5hVmHnHu *h8xuh8xumHnHu *h4mHnHu,< $$Ifa$gd. $Ifgdg$If$a$gdVgdV$a$gd8xu     vppdd $$Ifa$gd.$Ifkd$$Ifl0 $"F t0644 lapyt_U  * + , - vppdd $$Ifa$gd.$Ifkd$$Ifl0 $"F t0644 lapyt_U- . D E F G vppdd $$Ifa$gd.$Ifkd>$$Ifl0 $"F t0644 lapyt_UG H b c d e vppdd $$Ifa$gd.$Ifkd$$Ifl0 $"F t0644 lapyt_UH b c d e f      + A B C D I e i p q v w | } Ž蹫h_ johzYh.CJaJh.h8xuh8xu5h8xu hh@hh@hhIh35hhIhh@5hh@h4hh_Uh^hh Bh`hVAe f vppdd $$Ifa$gd.$Ifkd|$$Ifl0 $"F t0644 lapyt_U vppdd $$Ifa$gd.$Ifkd$$Ifl0 $"F t0644 lapyt_U vmmaa $$Ifa$gd. $IfgdhIkd$$Ifl0 $"F t0644 lapyt_U vpppdd $$Ifa$gd.$IfkdY$$Ifl0 $"F t0644 lapyt_U vtttnbb $$Ifa$gd.$Ifkd$$Ifl0 $"F t0644 lapyt_U B C xoc $$Ifa$gd. $Ifgd8xukd$$Ifl0 $"F t0644 lapythIC D p q xrff $$Ifa$gd.$Ifkd1$$Ifl0 $"F t0644 lapythI xocc $$Ifa$gd. $Ifgd_kd$$Ifl0 $"F t0644 lapythI  a b c d i  J L M N d ɽҨ疆vvgXTPh3hr>Sh4h5B*aJphh4h45B*aJph *hh45B*aJph *hh5B*aJph" *hh5>*B*aJphh_U5CJaJh *hhhh8xu5CJaJh5CJaJhh5CJaJh0'5CJaJh8xu5CJaJh`h_Uh_h,N b c d M N xvvvvvvvvvqqqgdkde$$Ifl0 $"F t0644 lapythI d e      M N GMNOP01AEsw!ﱭ筭穱ﱱhyVht h0'h3b}hh>*hh3>*h3hh@h h}4 *hh'3>* *hh}4h Bh)h8xuhhh5A M N OP0167ijgh^gd,N^gd8xu & Fgd!67agij=Ogh?CEF]efy MN_%qw12C lrսս *hh}4h}4h}4\ *hh,N h}4h}4h}4h}4>*h}4h,Nh Bh)h3h8xuh3b}JhEFefMN12 gh  & Fgd}4gdE & F gd}4^gd}4^gd,N & Fgd 6V\gh 5;=C /5|DJz~0 6 8 L >!D!!!!5";"="Q"""",#2#######{$$$$$%%%%hh}4h}45h Bh,Nh}4h}4>* h}4h}4S ##%%%&&&k(l(m(((((((( ) ) ) )))gdVgd  & F gd}4^gd}4%%%.&@&&&&&&& '''(()(k(l(m(o(y((((((((() ) ) ) ) )))))))))))))))))))6)7)ƾﲮ㮪hVjhVUh>?hEhhjhhUhRh hFvh8xuhC|5h8xuh8xu5 hr>S5h.h8xuh_h_h_5h0' *h8xuh8xuh3h3b}h0'h0'5CJaJ6))))))))))))):);)<)=)>)?))))$$V7)8)9):);)<)=)>)?)@)A)B)h h>?hEhhIhVjhVUmHnHuh BmHnHu 21h:p^/ =!"#$% $$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5Fpyt_U$$If!vh#v"#vF:V l t065"5FpythI$$If!vh#v"#vF:V l t065"5FpythI$$If!vh#v"#vF:V l t065"5FpythI$$If!vh#v"#vF:V l t065"5FpythIx666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH H`H XYNormal CJOJQJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List jj V Table Grid7:V04@4 V0Header  H$>/> V0 Header CharCJOJQJaJ4 @"4 V0Footer  H$>/1> V0 Footer CharCJOJQJaJDBD V OmniPage #3dL CJPJaJ@R@ 3b} List Paragraph ^6U a6 M0 Hyperlink >*B*phB' qB 0Comment ReferenceCJaJ<< 0 Comment TextCJaJB/B 0Comment Text CharOJQJ@j@ 0Comment Subject5\N/N 0Comment Subject Char5OJQJ\HH 0 Balloon TextCJOJQJ^JaJN/N 0Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y B!/^ 0247H d !%7)B)$&(*,. - G e C h )B) !"#%')+-*,7!@ @ 0(  B S  ?H0(   !!!!!!!!!@!C!}{| !!!!!!!!!@!C!3333333 -;eiLMNGGNNAEsw  f D F F  M M N N  % q w lrV\hh 5;=C /5|DJz~06>D5;,2{l m o y !! ! !!!9!:!D5;,2{l m o y !! ! !!!9!:!S_UZ`h=iBmdo8xu$'vFvC|3b} g{w_4hIIR^. O}4_/_.XYi<4h"00+3V ByV>?E) !!@B!@Unknown G.[x Times New Roman5^Symbol3. .[x Arial;^MWingdingsG.*{$ CalibriCalibri9. . Segoe UIC.,.{$ Calibri Light?= .Cx Courier NewA$BCambria Math"hFBIB;;!20  Kq@P $PV2!xxXN UTMBDavid Rodriguez$      Oh+'0`   ( 4@HPX'UTMB Normal.dotmDavid Rodriguez4Microsoft Office Word@^в@XZ@ ՜.+,0 hp  'UTMB Galveston;   Title  !"#$%&'()*+,-./12345679:;<=>?@ABCDEFGHIJKLMNOPQRSTUWXYZ[\]_`abcdehijmopqrstuvwxz{|}~Root Entry F@ l@ Data 01Table8y;WordDocument4^SummaryInformation(VDocumentSummaryInformation8^MsoDataStore  QXWWQOOZ5Q5Q==2Item  PropertiesUJAASF0NRPDFQ==2   Item  n5Properties }53DSEDB2==2 Item Properties!O  "#$%&( This value indicates the number of saves or revisions. The application is responsible for updating this value after each revision. i="http://schemas.microsoft.com/office/2006/metadata/properties/metaAttributes"/>DocumentLibraryFormDocumentLibraryFormDocumentLibraryForm   F Microsoft Word 97-2003 DocumentCompObj'r MSWordDocWord.Document.89q