ࡱ> AC@ X"bjbj 4*eeS(((8`,$(.6^<[ $!l(E{{{(m{L{: *NFR0Z,! $!!h{{{{{{{((1{{{{{{{!{{{{{{{{{ : APPENDIX B REPORT OF POTENTIAL CONFLICTS OF INTERESTS RELATED TO COURSE MATERIALS Complete this form if you answered YES to one or more of Questions 3-4 on the Annual Conflict of Interest/Commitment Statement-Attachment 1. Attach separate sheets and give the answer number for which additional information is provided. Use a separate form to report relationships with each enterprise or corporation. Name:  FORMTEXT       Banner ID:  FORMTEXT       Campus Address Room:  FORMTEXT       Building:  FORMTEXT       Local Address Street:  FORMTEXT       City/State:  FORMTEXT       Zip Code:  FORMTEXT       Rank:  FORMTEXT       Title:  FORMTEXT       Department:  FORMTEXT       Unit:  FORMTEXT       Campus Telephone:  FORMTEXT       Local Phone:  FORMTEXT       Email:  FORMTEXT       If you answered YES to Question 3 on the Annual Report, provide the information requested in ITEMS 1-2. Did you fully disclose the financial interest held by you or your family member in the publication or presentation?  FORMTEXT       2. If not, why not?  FORMTEXT         STf  4 6 J L N X Z \ ` δĥġΉĥΡyĥġij\hh 5Ujhh 5Ujthh 5UhDh 5h jh 5UmHnHujhh 5Ujh 5U h 5hjh 5 h\ h1\h3hp\ hp\ hm5\ hp5\)  7ST ^ `   Z \  $gd  ^`gd gd  7$8$H$gdp $7$8$H$a$gdp 0 2 F H J T V t v    . 0 D F H R T X Z \ p x ݽݥݝݍ}ݵݝjhh 5Uj,hh 5Uhjh 5jhh 5UhDh 5jDhh 5Ujhh 5U h 5h jh 5Ujh 5UmHnHu1x z  " $ . 0 L N b d f p r t nζx h 5\ hp5\jhh 5Ujphh 5Ujhh 5Uhjh 5jhh 5Uh jh 5UmHnHujhh 5U h 5jh 5U+ n   h7$8$H$^hgdp h7$8$H$^hgdm & F hh7$8$H$^hgdp 7$8$H$gdp $gd np  $&jl46f, r !!V!ıćććć|hp5B* \ph hpf35\hjhp56\!jBhmhgb;5U\ h 5\U!jhmhgb;5U\ hp5\ jhm5U\mHnHu!jXhmhgb;5U\ hm5\jhm5U\/ If you answered YES to Question 4 on the Annual Report, provide an explanation statement below.  FORMTEXT       SIGNATURES: I certify that all of the above information is correct and that I will promptly update information as changes occur. ____________________________________________ ________________________ Employee Signature Date ____________________________________________ ________________________ Department Chair Date ____________________________________________ ________________________ Dean (where applicable) Date ____________________________________________ ________________________ Standing Committee on Conflicts of Date Interest and Commitment (where applicable)     Confidential Annual Conflict Assessment Personnel Record 10/31/14   $&h. p r t v !V!!!! h7$8$H$^hgdp 7$8$H$gdpV!!!!!!!!!!!!<">"R"T"V"X"h^Ch hgb;hmhm5CJaJh!jh!Uh hp5h3hp5!!!!!!!!"<">"P"R"T"V"X"21h:p / =!"#$% tDText1tDText3tDText2tDText2tDText3tDText2tDText2tDText2tDText2tDText3tDText2tDText7tDText2tDText2tDText9vDText10vDText11^ 02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ pNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4@4 mHeader  !4 @4 m0Footer  !6o6  0 Footer CharCJaJH@"H   Balloon TextCJOJQJ^JaJNo1N  Balloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] * GGRRRU x nV!X"  !X" #BNTdpv/;AP\bmyams%+FFFFFFFFFFFFFFFFF8@0(  B S  ?Text1Text2Text3Text7Text9Text10Text110bBt,aaooux,-.00DE]z*..z@<.^`o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.z@<          B&V!/F/x0pf3gb;^CHRkSifpmMk1!x^@@@ UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"hG*G*d d r43QHX ?p*!xx  APPENDIX BingramnYvonne L. Halley Oh+'0@x    (08 APPENDIX BingramnNormalYvonne L. Halley2Microsoft Office Word@@rN@rNd՜.+,0 hp  (Ӱԭ A & T State University   APPENDIX B Title  !"#$%&'()*+,-./12345679:;<=>?BRoot Entry F-ϲNDData 1Table"WordDocument4*SummaryInformation(0DocumentSummaryInformation88CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q