Form 24 COI Screen

NCI CIRB
MEMBER CONFLICT OF INTEREST SCREENING WORKSHEET
OMB #0925- xxxx

Expiry Date: xx/xx/xxxx

Collection of this information is authorized by The Public Health Service Act, Section 411 (42 USC 285a). Rights of your participation in the
NCI CIRB is protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing
from the NCI CIRB at any time. Refusal to participate will not affect your benefits in any way. The information collected will be kept private
to the extent provided by law. Names and other identifiers will not appear in any report of the NCI CIRB. Information provided will be
combined for all participants and reported as summaries. You are being requested to complete this instrument so that we can conduct activities
involved with the operations of NCI CIRB Initiative.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda,
MD 20892-7974, ATTN: PRA (0925-0625*). Do not return the completed form to this address.

MEMBER NAME:
DATE COMPLETED:

The CIRBs follow standard operating procedures (SOPs) to ensure compliance with federal
regulations and guidance. These SOPs include a Conflict of Interest Policy for CIRB members.
A copy of this policy has been provided to you via email.
Identification and management of CIRB Member conflicts of interest is essential to maintaining
the integrity of the NCI CIRB’s reviews. This form is meant to help members and the CIRB
Operations Office identify a member’s actual or perceived conflicts of interest per CIRB SOPs.
Please complete this worksheet and return to the NCI CIRB Administrator, John Horigan, via
email at [email protected].

1. CIRB Standard Operations Procedures (SOPs) prohibit employees of the NCI from serving on the
NCI CIRB [SOP 4.2.4].
Are you an employee of the NCI?
No.
Yes.

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2. The CIRB SOPs prohibit employees of the NCI from serving on the NCI CIRB, but in some cases,
individuals who are not employed by NCI but who have a working relationship with NCI in another
capacity (e.g. a contractor or consultant, or serving on an NCI Disease-Specific Steering
Committee) may be perceived as having a conflict of interest.
Do you have any such relationship with NCI?
No.
Yes. If yes, describe the relationship in the space below.

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3. Individuals who have a primary role (e.g. member of a network group disease committee or a
study chair) in the oversight, design or conduct of a study (or a particular subset of studies) under
review by the CIRB are considered to be conflicted for those studies and may be too frequently
conflicted to serve on the CIRB.
A conflict also exists if an immediate family member (i.e. spouse, significant other, dependent
child) or an individual in a direct supervisory or reporting relationship to the member has such a
role (e.g., a boss or employee). [SOP 4.11.3.1]
Do you, an immediate family member, or an individual in a direct supervisory or reporting
relationship to you have a primary role in the oversight, design or conduct of a study (or a
particular subset of studies) under review by the CIRB?

CIRB Candidate (You)
No.
Yes. Indicate which
study/studies:

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
study/studies:

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
study/studies:

4. Individuals who have a role in the analysis or management of data for a study or for a particular
subset of studies under review by the CIRB are considered to be conflicted for those studies and
may be too frequently conflicted to serve on the CIRB.
A conflict also exists if an immediate family member (i.e. spouse, significant other, dependent
child) or an individual in a direct supervisory or reporting relationship to the member has such a
role (i.e., a boss or employee). [SOP 4.11.3.1]
Do you, an immediate family member, or an individual in a direct supervisory or reporting
relationship to you have a role in the analysis or management of data for a study or for a
particular subset of studies under review by the CIRB?

CIRB Candidate (You)
No.
Yes. Indicate which
study/studies:

Page 3 of 6

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
study/studies:

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
study/studies:

5. Individuals who serve on a governing body or any significant supervisory committee of the
coordinating group that submits studies for CIRB review, such as a Disease Committee, the
Board of Directors, or a Data Monitoring Committee of the coordinating group are considered to
be conflicted for those considered to be conflicted for those studies and may be too frequently
conflicted to serve on the CIRB.
A conflict also exists if an immediate family member (i.e. spouse, significant other, dependent
child) or an individual in a direct supervisory or reporting relationship to the member has such a
role (i.e. a boss or employee). [SOP 4.11.3.1.1]
Do you, an immediate family member, or an individual in a direct supervisory or reporting
relationship to you, serve on a governing body or any significant supervisory committee of
the coordinating group that submits studies for review by the CIRB?

CIRB Candidate (You)
No.
Yes. Indicate which
coordinating group(s):

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
coordinating group(s):

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
coordinating group(s):

6. Individuals who serve as Study Chairs of currently active studies (open to accrual) or who are
employed by the same institution as Study Chairs may be considered to be conflicted for those
studies and may be too frequently conflicted to serve on the CIRB.
A conflict also exists if an immediate family member (i.e. spouse, significant other, dependent
child) or an individual in a direct supervisory or reporting relationship to the member has such a
role (i.e. a boss or employee). [SOP 4.11.3.1.2 and SOP 4.11.3.2]
a. Do you, an immediate family member, or an individual in a direct supervisory or reporting

relationship to you, serve as a Study Chair of a currently active study?

CIRB Candidate (You)
No.
Yes. Indicate which
study/studies:

Page 4 of 6

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
study/studies:

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
study/studies:

b. To the best of your knowledge, are you, an immediate family member, or an individual in a

direct supervisory or reporting relationship to you, employed by the same institution as
the Study Chair of a currently active study?

CIRB Candidate (You)
No.
Yes. Indicate which
study/studies:

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
study/studies:

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
study/studies:

7. Please list institutions with which you, an immediate family member, or an individual in a direct
supervisory or reporting relationship to you, have an affiliation (as a consultant, contractor, or
employee). [SOP 4.11.3.2]

CIRB Candidate (You)

Immediate family member
(i.e. spouse, significant other,
dependent child)

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)

If applicable.

If different from your own.

1.

1.

1.

2.

2.

2.

3.

3.

3.

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8. Individuals who have a significant financial interest in any oncology-related
agents/devices/enterprises may be considered to be conflicted for studies involving those
agents/devices/enterprises (or agents/devices/enterprises developed by direct competitors) and
may be too frequently conflicted to serve on the CIRB.
A conflict also exists if an immediate family member (i.e. spouse, significant other, dependent
child) or an individual in a direct supervisory or reporting relationship to the member has such a
role (i.e. a boss or employee). [SOP 4.11.3.3, 4.11.3.3.1, 4.11.3.3.2, 4.11.3.3.3]
a. Do you, an immediate family member, or an individual in a direct supervisory or reporting

relationship to you, have a financial interest of $5,000 or more in any oncology-related
agents/devices/enterprises?

CIRB Candidate (You)
No.
Yes. Indicate which
agents/devices/enterprises:

Immediate family member
(i.e. spouse, significant other,
dependent child)
No.
Yes. Indicate which
agents/devices/enterprises:

Individual in a direct supervisory
or reporting relationship to the
CIRB Candidate
(i.e. your boss or your employee)
No.
Yes. Indicate which
agents/devices/enterprises:

b. Have you, or an immediate family member received any compensation from any
oncology-related enterprise within the last two years?
CIRB Candidate (You)
No.
Yes. Indicate which agents/devices/enterprises:

Page 6 of 6

Immediate family member
(i.e. spouse, significant other, dependent child)
No.
Yes. Indicate which agents/devices/enterprises: