Campus Community Health • HEERF I, II & III

Office of Research

Compliance Certification

Complete this form in regard to the current project designated in the Project Title field below and submit it to the Office of Research. Please note that this form cannot be completed by a proxy. If you mark "yes" to any of these questions, please contact the Office of Research at research@tntech.edu.

Certifications: Please note that by completing and submitting this form, you certify that:

(1) The information submitted within the application is true, complete, and accurate to the best of your knowledge.
(2) You understand that any false, fictitious, or fraudulent statements or claims may subject you to criminal, civil, or administrative penalties.
(3) You are qualified to perform the work outlined in this proposal.

Have you been debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any federal department or agency?
Please answer yes or no.
Have you, within a three-year period preceding this proposal, been convicted of or had a civil judgment rendered against you for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; violated federal or state antitrust statutes or committed embezzlement, theft, forgery, bribery, falsified or destroyed records, made false statements, or received stolen property?
Please answer yes or no.
Are you presently being indicted for or otherwise criminally or civilly charged by a governmental entity (federal, state or local) with commission of any of the offenses numerated in the question above?
Please answer yes or no.
Have you, within a three-year period preceding this application/proposal, had one or more public transactions (federal, state or local) terminated for cause or default?
Please answer yes or no.
Note: By marking "No" in this section, you certify that no lobbying has been done prior to the proposal being approved and that no lobbying will be done after it has been approved. To the best of your knowledge, have any lobbying activities been conducted relative to this proposal?
Please answer yes or no.
Note: The following four questions pertain to conflict of interest (Reference: Office of Research Conflict of Interest in Research Policy 735; Code of Federal Regulations on Financial Conflict of Interest, 45 CFR Part 94.1; and Public Health Service Regulation 42 CFR Part 50.601). 
Are you or any member of your immediate family (spouse, parents, parents-in-law, siblings, children, other relatives living at the same address as you, or reported as dependents on federal income tax forms) an officer, director, partner, trustee, employee, advisory board member, or agent of the external organization funding this project or of any organization from which goods and services will be obtained under this project?
Please answer yes or no.
Do you or any immediate family member have any significant financial interest including, but not limited to, salary or other payments for services (greater than $10,000 per year from sources other than the employee's institution), equity interest (greater than $10,000 in value or more than 5% of the ownership interest in a single entity), and intellectual property rights in the external organization funding this project or of any organization from which goods and services will be obtained under this project?
Please answer yes or no.
Do you have any affiliation with the external organization that would diminish your ability to fulfill your paramount obligations to your students, your colleagues, or the University; or have you involved any student in a proprietary capacity with the external organization?
Please answer yes or no.
I certify that I
Please make a selection from the following:

 
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