Approval of Relationship with LSC by Supervisor Form

The supervisor of all University faculty, staff, and students who seek to take equity in a LSC and/or serve in a management or officer position, such as CEO, must sign the Approval of Relationship with Licensed Start-up Company (LSC) by Supervisor form.

Sign an Approval Form Electronically

Visit our Forms and Guides page to complete the approval form electronically via DocuSign.

Standard Terms

The supervisor of the faculty member, staff member, or student signing a PCS will agree to the following standard terms:

  1. My approval of this individual’s proposed involvement with this company is contingent upon their continued ability to meet their responsibilities to the department and/or school.
     
  2. If the individual is a full-time faculty member, this individual has appropriate time available to perform the currently proposed services for the company, if any. I understand that under University Policy 11-01-03 I am responsible for monitoring compliance with the Licensed Start-Up Company
    (LSC) Policy Compliance Statement and any COI Management Plan(s) developed by the COI Office, including the requirement that covered individuals spend no more than one day per week on the average of their University time on approved outside professional activities, including work for this company, over the period of their contractual appointment at the University and during any summer month in which they receive compensation for teaching, research, or other University activities.
     
  3. If the individual is staff, a postdoctoral or other trainee, or a student, all of this individual’s work on behalf of the company is required to occur outside normal working hours at the University.
     
  4. The individual involved in this relationship may make only “Incidental Use” (as defined and described in sections II.H and III.E of Policy 11-01-03) of University resources to support the company or other outside interests. I understand that, as applicable, I am responsible for approval of “Incidental Use” of any University resources. I understand that in no case is University or UPMC confidential data, funds, trademarks, or logos permitted to be used in performing outside work for the company.
     
  5. I will inform the COI Office of any additional restrictions or requirements I place on this relationship beyond those outlined in the Licensed Start-Up Company (LSC) Policy Compliance Statement and any COI Management Plan(s) developed by the COI Office.
     
  6. I understand that I have an affirmative obligation to the University to monitor this relationship and to notify the Conflict of Interest Committee if the individual fails to comply with the Conflict Management Plan or any of the above assurances.