Disclosure Supplement

This “smart form” is to be used instead of the regular disclosure summary for industry sponsored clinical trials. It is designed to collect information needed by the campus Conflict of Interest Review Committee for its review of your financial interests. In completing the form, you will be prompted to provide details only about those categories (i.e. income, investments, management positions, etc.) of financial interests that you have disclosed. The form can be either printed and mailed or saved as a PDF file and e-mailed to your Office of Clinical Trials Contract Analyst.

All Principal Investigators and other Investigators who share responsibility for the design, conduct or reporting of an industry sponsored clinical trial and who have reported a financial interest on either Form 700-U or 700-U Addendum must complete this form. Completion of this form is required in accordance with UCLA Policy 925. Per the California Public Records Act, the information may be released to the public upon request.



Section A: Profile

* Required Field

Investigator :  
Last Name * :
  First Name * :
  Middle Initial :
Principal Investigator (if different) :  
Last Name :
  First Name :
  Middle Initial :
Name of Entity in Which You Have a Financial
Interest * :
IRB Organization * :
IRB Status * :
Protocol Title* :
Study Protocol Type* :
Your Roles and Responsibilities in this clinical trial. Please check all that apply * :
Recruitment of subjects
Consent of subjects
Data collection
Data analysis
Conduct of the project
Reporting of the project to sponsors
Treatment of subjects
Authorship of publications
Design of study protocol