About Public Health Service (PHS) Financial Conflicts of Interest Regulations

PHS Financial Conflict of Interest Information Request

Please use this form for all requests for information regarding the financial conflicts of interest of senior and key personnel participating in research at St. Jude Children's Research Hospital that is funded by the Public Health Service (PHS).

Please complete one form for each individual investigator for whom information is requested.

Asterisk (*) indicates a required field.

Requestor Contact Information

First Name*

Last Name*

Address 1*

Address 2

City*

State/Province/Region*

Zip/Postal Code*

Email Address*

Phone Number*

Investigator Information

First Name*

Last Name*

Reason you are requesting this information:

Comments

Submission

Upon receipt of a completed form, St. Jude will provide, within 5 working days, the investigator's name, title, and role with respect to the PHS research project(s), along with the name of the entity in which the FCOI is held and the nature and approximate dollar value of the FCOI or a statement that the interest is one whose value cannot be readily determined through reference to public prices or other reasonable measures of fair market value.

I agree to share this information with St. Jude*
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