### View/Modify Request 21094 (instructions)

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### REPA data Submitted

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Report of External Professional Activities (REPA)

The REPA form is designed to help you comply with the provisions in the University policies that govern external professional conduct, activities, and interests: Code of Conduct; Outside Consulting, Service Activities, and Other Work; and Conflict of Interest. Faculty and staff are required, at least annually, to complete and submit a REPA for review and approval prior to the announced deadline.

Instructions
Preparing or Modifying a REPA form
Reviewing and Approving a REPA form
EGMS Technical Helpline (612)624-1600
REPA Policy Helpline (612)626-1462
E-mail Help or Comments repa@egms.umn.edu

Create Date: 08/06/04 | RID: 21094 | REPORTING YEAR:
Prepared by: davis125 | for: DeGross,James Wilfred (j-degr)

Appointment Data |
Name: | DeGross,James Wilfred
Academic Title/Rank: | Assistant To
Department/Unit: | Surgery
College: | MEDICAL SCHOOL
Term of Appointment: | 12 months - A appointment
Total Percent of Employment: | 100
Approvers |
The approvers needed are based on your demographic information as entered at the top of this form. The REPA forms for some individuals and in some colleges do not need a departmental approval signature.
Departmental Approver (Academic Head/Chair/Director) |
To change the departmental approver for this form, replace the Internet ID listed with the Internet ID of the departmental approver that needs to review this form. Internet IDs can be looked up in the University directory and are case-sensitive. To look up an Internet ID, use this link to access the directory.
Name: | Dunn,David L
Collegiate Approver |
Collegiate approval information is centrally maintained and cannot be changed here.
Name: | Moldow,Charles F (moldo002)

Part I: General Questions
If you answer "Yes" to any of the general questions, you must provide additional information below for the purpose of gathering details on the external professional activities and interests. If you answer "No" to all the general questions in this part, you may skip to the end of this form.
Question 1 asks about previous activities. Answer Question 1 for any external professional activities engaged in during the REPA reporting period.
1: | Regardless of compensation, did you provide professional services that were related to your University activities to at least one outside organization, where the total time of service to a single organization exceeded three days over the course of the REPA reporting period?
| Yes No (If yes, please complete Part II)
Questions 2, 3, and 4 ask about both previous interests and interests during the next 12 months. Answer these questions for any financial or business interests engaged in during the REPA reporting period or expected to be engaged in during the next 12 months.
2: | Did, or will you, a member of your immediate family, or an associated entity (e.g. a trust) have a financial interest from or in a business that relates to your University activities and that equals or exceeds either: income of $10,000 from that business (including but not limited to royalties, consulting fees, and/or dividends), or an equity interest in that business valued at $10,000 or representing 5% ownership (regardless of worth)?
| Yes No (If yes, please complete Part III)
3: | Did, or will you, a member of your immediate family, or an associated entity (e.g. a trust), regardless of compensation, serve on a board of directors or advisory board for a business that supports (through gifts or sponsored support) your University research?
| Yes No (If yes, please complete Part IV)
4: | Did, or will you, a member of your immediate family, or an associated entity (e.g. a trust), regardless of compensation, hold an executive position in a business that engages in commercial or research activities that relate to your University activities?
| Yes No (If yes, please complete Part IV)
If you have answered "No" to all 4 general questions, you may skip to the end of this form and use the Re-Submit Request button to submit the form.

Part II: Outside Consulting, Service, & Other Work
(to be completed only if General Question 1 was answered "Yes")
For each organization to whom you provided professional services of more than three days duration, complete a Details of External Professional Activity entry describing the services.

Details of External Professional Activity
Name of Organization | Description of Activity
Type of Organization
Type of Compensation
Number of Days (responses allowed to the quarter day; eg 6.25) | ROC details - if Filed (Request for Consultant or Outside Service Agreement)
on campus | off campus | total | ROC Approval Date | EGMS ROC ID Number
|  |  | (mm/dd/yy) | (if filed using EGMS)

Click Next Organization to add another entry table. |
Cumulative Days:
on campus | off campus | total

Part III: Financial Interests (to be completed only if General Question 2 was answered "Yes") |
Answer the following questions as they relate to financial interests engaged in during the REPA reporting period or expected to be engaged in during the next 12 months. |
Royalties |
1: | Have you received or will you receive, or be entitled to receive, royalties from the University or from another academic institution's royalty-sharing policy?
| Yes No |
| For instances where the above answer is Yes, did you or will you:
| a) | Assign students, postdoctoral fellows, or other trainees to research projects related to activities for which you have received, will receive, or will be entitled to receive royalties?
|  | Yes No
| b) | Participate in funded or unfunded research on a technology, process or product development related to the activities for which you have received, will receive, or will be entitled to receive royalties?
|  | Yes No
Financial Interests |
2: | Regarding the previous or expected financial interest from or in a business that relates to your University activities, does that business provide funds (gifts or sponsored support) for your University research?
| Yes No |
| For instances where the above answer is Yes, did you or will you:
| a) | Assign students, postdoctoral fellows, or other trainees to projects supported by those funds?
|  | Yes No
| b) | Participate in research using those funds?
|  | Yes No
3: | Regarding the previous or expected financial interest from or in a business that relates to your University activities, was or will that interest be of a nature other than consulting income and/or publishing royalties?
| Yes No | Note: Answer No if your financial interest is limited to consulting income and/or publishing royalties, and there is no other relationship between the business(es) for which you consult or from which you receive royalties and your University work.
| For instances where the above answer is Yes, did you or will you:
| a) | Assign students, postdoctoral fellows, or other trainees to instructional projects related to that business?
|  | Yes No
| b) | Participate in clinical trials or evaluation or development of a technology, process, or product owned or controlled by that business?
|  | Yes No
| c) | Make professional referrals to that business while acting in the context of your University duties?
|  | Yes No
| d) | Take administrative action on behalf of the University with respect to any University-affiliated organization that is related to that business?
|  | Yes No
| e) | Take administrative action on behalf of the University with respect to any supported research activity that is related to that business?
|  | Yes No

Part IV: Disclosure of Potential Conflicts of Interest (to be completed only if General Questions 3 or 4 or a subquestion in the Financial Interests section is answered Yes) |
For each earlier Yes answer, as identified above: Identify the entities in which you previously had or expect to have a financial or business interest; Describe the nature of your previous interests or expected interests (e.g., royalties, equity interest, consulting income, executive position, member of the board of directors or advisory board); Explain the relationship between your previous interests or expected interests and your University responsibilities; Describe any previous involvement or expected involvement by students, and whether you serve as their primary advisor; and Explain the mechanisms that have been or will be instituted to minimize the chances of conflict of interest occurring. |
Note: When providing supplemental disclosure information in the box below, remember to include information about financial and business interests. |
Supplemental Disclosure Information (3000 character limit) |
1. Have any of the relationships described above been previously disclosed on a REPA? |
Yes No
| a) If yes, has the nature of your financial and/or business relationship changed?
| Yes No
| b) If yes, has your research role at the University of Minnesota changed regarding this relationship?
| Yes No
Additional Information (3000 character limit) |
Relationships between Financial or Business Interests and Sponsored Projects |
Are any of your previous or expected financial or business interests related to your sponsored projects?
Yes No
If Yes, please list the sponsored projects below. List only those projects that relate to financial or business interests disclosed in this REPA.

Sponsored Project Details
Identify the financial or business interest to which this sponsored project is related.
Project Title |  |
Funding Source |
Principal Investigator |  |
Project Dates (mm/dd/yy) | to
Annual Support $ |

Click Next Sponsored Project to add another data entry table. |

Preparer's Comments
None

Prepared By | davis125 Davis,Melinda J | Phone # | (612) 624-1600

APPROVALS AND CERTIFICATIONS
Academic Employee:
I certify that the outside activities and interests reported here are accurate to the best of my knowledge.
Department/Unit Head and Collegiate Official:
I certify that I have reviewed the information reported here and determined to the best of my knowledge that: 1) the employee's outside activities comply with the Regents Policy on Outside Consulting, Service Activities, and Other Work and 2) the employee's outside activities and interests do not present a potential conflict of interest, or if so, the conflict is managed to the University's satisfaction following the process outlined in the Regents Policy on Conflict of Interest.

### Process this Form

Comments

Notes
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### Request History

1 | 06-AUG-04 | davis125 | Created
2 | 06-AUG-04 | repa-sanity | Signed
Looks good!
3 | 06-AUG-04 | repa-refnextappr | Signed
next approver is j-degr
4 | 06-AUG-04 | j-degr | Signed
5 | 06-AUG-04 | repa-refnextappr | Signed
next approver is dunnx002
6 | 06-AUG-04 | dunnx002 | Referred
7 | 06-AUG-04 | repa-refnextappr | Signed
next approver is moldo002
8 | 06-AUG-04 | moldo002 | Referred
9 | 06-AUG-04 | repa-refnextappr | Signed
next approver is bexxx001
10 | 06-AUG-04 | bexxx001 | Signed
CRC: looks good
11 | 06-AUG-04 | repa-refnextappr | Signed
next approver is moldo002
12 | 11-AUG-04 | moldo002 | Signed
OK from moldo002 in REPABATCH document 24870
13 | 11-AUG-04 | repa-refnextappr | Signed
next approver is dunnx002

### Actions needed for Approval

Action | Who/What
--- | ---
SignRef | dunnx002 (repaapprover) (repaapp_alt)
TestConstant | repanomoreapprs,GO4
BranchIfNotEqual | more_apprs

### Current Status

Request Number | Form | Status | Summary
--- | --- | --- | ---
21094 | REPA | Pending.. | 2004 REPA for DeGross,James Wilfred

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