Pharmacology Research Collaboration Disclosure Form
1. Researcher Information
Full Name
Email Address
Institution / Organization
Role in Research
2. Research Project Information
Project Title
Project Description
List of Collaborators (Names & Institutions)
3. Funding & Financial Disclosure
Sources of Funding
Financial Interests (e.g., stocks, honoraria)
4. Intellectual Property / Patents
Describe Any Related Intellectual Property or Patents
5. Other Relevant Disclosures
Other Potential Conflicts or Relevant Information
6. Certification
By signing below, I certify that the information provided is accurate and complete to the best of my knowledge.
Signature
Date