Form 93 Fin Disclosure

Attachment E03 – NCI/DCTD/CTEP Financial Disclosure Form

OMB #xxxx-xxxx
Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to average 5 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 208927974, ATTN: PRA (OMB #xxxx-xxxx). Do not return the completed form to this address

Screenshots

Figure 1: Electronic Capture of the Financial Disclosure Form

Breakdown of Elements
There are four different Yes/No questions of the Financial Disclosure Form that are
electronically captured, with an option to provide additional information if the investigator
answered ‘Yes’ to any of the questions:
1. Do you currently have or have you at any time in the past year had any financial
arrangement entered into between the sponsor of the covered study and the
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clinical investigator involved in the conduct of the covered study, whereby the
value of the compensation to the clinical investigator for conducting the study
could be influenced by the outcome of the study?
2. Have you had any significant payments of other sorts made on or after February
2, 1999, from the sponsor of the covered study, such as a grant to fund ongoing
research, compensation in the form of equipment, retainer for ongoing
consultation, or honoraria?
3. Do you currently have or have you at any time in the past year had any
proprietary interest in the product tested in the covered study held by the clinical
investigator?
4. Do you currently have or have you at any time in the past year had any
significant equity interest, as defined in 21 CFR 54.2(b), held by the clinical
investigator in the sponsor of the covered study?
If the investigator answered ‘Yes’ to any of the above questions, a field will appear
where the investigator can add the following information:
1.
2.
3.
4.
5.

Add New Record: Allows the investigator to add a new record of information.
Delete: Allows the investigator to update or delete a row of information.
CTEP ID: The CTEP ID of the pharmaceutical company.
Pharmaceutical Company: The name of the company.
Site Address: The address of the pharmaceutical company

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