Conflicted Investigator(s)

Personnel Identification

List all personnel subject to data steward oversight that will be addressed in this report.

Conflicted Investigator Name(s) - List one per line	Conflicted Investigator Department
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Project or Study Listing

List all human subject, animal, and/or bench research projects subject to data steward oversight that will be addressed in this report. Provide specific protocol and/or grant numbers where possible.

Protocol or Grant Number	Full Project or Grant Title
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Data Steward/Data Steward Committee

Personnel Information

List name(s) of the data steward(s) and/or members of the data steward committee along with their departments.

Data Steward Name(s) - List one per line	Data Steward Department
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List of Study Team Members

List name(s) and position(s) of personnel with whom the data steward(s) met.

Study Team Name(s) - List one per line	Study Team Position(s)
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Date(s)

Provide date(s) the data steward(s) met with the study team members in MM/DD/YYYY format.

Meeting Date 1	Click or tap to enter a date.
Meeting Date 2	Click or tap to enter a date.
Meeting Date 3	Click or tap to enter a date.

Date of This Submission	Click or tap to enter a date.

Report of the Data Steward(s)

Summary

Please provide a summary of relevant discussions with the study team(s) pertaining to data collections and interpretation or any bias in the results or conduct of the research that may exist or appear to exist as a result of the Investigator’s conflict.

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Data Analysis Considerations

If data analysis considerations were applicable, please answer the following questions by typing Yes, No, or NA in the designated fields:

Is inclusion or exclusion of data well justified based upon the study protocol? If no, give details below.

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Do the statistical analyses correspond to those that were planned and described in the study protocol, including variables designated as primary and secondary outcomes? If no, give details below.

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Are the results that are presented in the project report representative of the statistical analyses? If no, give details below.

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Were any data not included in the results? If yes, give details of the reason below:

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Are the conclusions presented in the project report appropriate to the results? If no, give details below.

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Do you see reason to be concerned that the financial interests of the conflicted investigator(s) led to bias in data collection, data interpretation, or reporting of results during this project, or otherwise biased the objectivity of any investigator working on the project? If yes, please give details below.
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Conclusions

Please select one of the following:

☐	I do not have any concerns regarding data collection and interpretation, or that the conflicted investigator(’s) financial interest(s) led to any bias in the results or conduct of the research.
☐	I do not have any concerns regarding data collection and interpretation, or that the conflicted investigator(’s) financial interest(s) led to any bias in the results or conduct of the research. I do, however, have suggestions that may lead to improvements in the integrity of the data and remove any potential future concerns about conflict of interest bias.
☐	Other Under “Additional Remarks” below, please summarize any concerns that you or members of the study team have regarding data collection and interpretation, or bias in the results or conduct of the research as a result of the investigator’s conflict.

Additional Remarks (Optional)

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