Summary Disclosure of Financial Interests (Page 1 of 6)

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Completion of this form is mandatory for all proposals submitted via RFS and for protocols with a disclosed COI submitted to the IRB. This information is required to comply with the University of Massachusetts Medical School Policy for Promoting Objectivity in Biomedical Research and applicable federal and state laws and regulations regarding timely and proper disclosure of financial interests. This disclosure form conforms with the requirements of PHS FCOI regulations available at