THE JOHN B. PIERCE LABORATORY CONFLICT OF INTEREST DISCLOSURE FORM Investigator’s Name:

Publicly Traded Entities: In accordance with PHS regulations, a significant financial interest exists if the value of any remuneration received from any publicly traded entity in the twelve months preceding the disclosure and the value of any equity interest in the entity as of the date of disclosure, when aggregated, exceeds $5,000. [...] (b) As of the date of this disclosure, do you, your spouse or your dependent children hold any equity interests in a publicly-traded entity? If so, does the value of this equity exceed $5,000 (U. [...] (b) During the past 12 months, did you, your spouse or your dependent children hold ANY equity interests in any non-publicly traded entity? NO ____ YES ____ If yes, complete table below Name of Entity Type of Business Type of Equity Value in U. [...] I will take into consideration the role of the investigator, rather than their title and the degree of independence with which the investigator will work; • If I am a PI, I will complete my progress report in a timely fashion to assist the PHS Grantee in its reporting requirements related to any identified and previously reported FCOIs; • That The John B. [...] Pierce Laboratory’s response must be within 5 business days and will include: o My name; o My title and role with respect to the research project; o The name of the entity in which the significant financial interest is held; o The nature of the significant financial interest; and o The approximate dollar value of the significant financial interest will be provided in the following dollar ranges: $.