https://urldefense.proofpoint.com/v2/url?u=https-3A__webportalapp.com_webform_conflictofinterest-2Dprstrt&d=DwMFaQ&c=cpvmSBWXd8YiHoMtYk_a9E2QIiaEheG3-gfMB16YPq0&r=MeygN9dPoUQ6pO-I8aRt-ZI-AWqeyI4vexO-g0SLlUI&m=BjkiSGr8MN4zu5l0_ykvPJCIfoZKJ8fR7cz84y47C1o&s=mDWJ60EoLOJHYm2h6AxSbhvdkSFWOblrgXtv4x_NH8g&e=

Last Checked: Apr 23, 2019, 10:19 EDT

IP Address: 67.231.154.66
ASN #: AS22843 PROOFPOINT-ASN-US-EAST - Proofpoint, Inc., US
Location: Data unavailable.
URL Reputation:
  • Unknown This URL is not identified as malicious in the PhishTank Database.
  • Unknown PhishCheck thinks this URL is likely not a phish.
  • Unknown OpenPhish: URL not in feed.

Other submissions on 67.231.154.66:

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Previous checks:

                               fgets: Connection reset by peer

                             
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    302 Found

    https://urldefense.proofpoint.com/v2/url?u=https-3A__webportalapp.com_webform_conflictofinterest-2Dprstrt&d=DwMFaQ&c=cpvmSBWXd8YiHoMtYk_a9E2QIiaEheG3-gfMB16YPq0&r=MeygN9dPoUQ6pO-I8aRt-ZI-AWqeyI4vexO-g0SLlUI&m=BjkiSGr8MN4zu5l0_ykvPJCIfoZKJ8fR7cz84y47C1o&s=mDWJ60EoLOJHYm2h6AxSbhvdkSFWOblrgXtv4x_NH8g&e=

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    200 OK

    https://webportalapp.com/webform/conflictofinterest-prstrt

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    200 OK

    https://webportalapp.com/js/jquery-1.9.1.min.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/css/fontawesome/font-awesome.min.css

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/css/jquery.fileupload.css

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/css/wigeon-custom.css?v=22.2.0.5

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    200 OK

    https://webportalapp.com/css/select2.min.css

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    200 OK

    https://webportalapp.com/lightbox/css/lightbox.css

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    https://webportalapp.com/css/bootstrap-datetimepicker.min.css

  • GET
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    200 OK

    https://webportalapp.com/webform/webform.css?v=22.2.0.5

  • GET
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    200 OK

    https://webportalapp.com/js/moment.min.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/css/bootstrap/default/js/bootstrap.min.js

  • GET
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    200 OK

    https://webportalapp.com/js/bootstrap-datetimepicker.min.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/css/bootstrap/default/css/bootstrap.min.css

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/jquery.ui.widget.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/jquery.iframe-transport.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/select2.min.js?v=22.2.0.5

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/lightbox/js/lightbox.min.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/bignumber.min.js

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/zengine-form.js?v=22.2.0.5

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    200 OK

    https://webportalapp.com/js/zengine-filter-matcher.js?v=22.2.0.5

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    https://webportalapp.com/js/jquery.fileupload.js

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    HTTP/1.1
    200 OK

    https://webportalapp.com/js/zengine-field-rules.js?v=22.2.0.5

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    HTTP/1.1
    200 OK

    https://webportalapp.com/js/wh-import-export-inject.js?v=22.2.0.5

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    HTTP/1.1
    200 OK

    https://webportalapp.com/js/wh-import-export-api.js?v=22.2.0.5

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/common.js?v=22.2.0.5

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/webform/webform.js?v=22.2.0.5

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/js/post-robot.min.js?v=22.2.0.5

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/img/pbwh.png

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    https://webportalapp.com/lightbox/images/prev.png

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    https://webportalapp.com/lightbox/images/close.png

  • GET
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    https://webportalapp.com/lightbox/images/loading.gif

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    https://webportalapp.com/lightbox/images/next.png

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    200 OK

    https://webportalapp.com/webform/logo/conflictofinterest-prstrt/-LMbmcoC8RH_MPxagPb8

  • GET
    HTTP/1.1
    200 OK

    https://webportalapp.com/favicon.ico

  • https://urldefense.proofpoint.com/v2/url?u=https-3A__webportalapp.com_webform_conflictofinterest-2Dprstrt&d=DwMFaQ&c=cpvmSBWXd8YiHoMtYk_a9E2QIiaEheG3-gfMB16YPq0&r=MeygN9dPoUQ6pO-I8aRt-ZI-AWqeyI4vexO-g0SLlUI&m=BjkiSGr8MN4zu5l0_ykvPJCIfoZKJ8fR7cz84y47C1o&s=mDWJ60EoLOJHYm2h6AxSbhvdkSFWOblrgXtv4x_NH8g&e= https://webportalapp.com/webform/conflictofinterest-prstrt
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		<link href="/css/bootstrap-datetimepicker.min.css" rel="stylesheet">
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	<body>
				<script type="text/javascript">
	/**
	 * Includes our X-TOKEN to all jquery requests
	 *
	 * To keep it simple it will override the beforeSend and error handler for all
	 * jQuery ajax requests.
	 *
	 * The beforeSend/error handlers are called after the initial setup is in place.
	 *
	 * This function will include X-TOKEN to all jQuery requests, and will check the error,
	 * and if the error is invalid token it will retry the last request with a new X-Token.
	 */
	$(function() {
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	window.wg = function() {

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			options.error = handleAjaxError;

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		wg.errorAlert = function(message, code) {
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		wg.callPing = function() {
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<div class="row" style="margin: 0;">
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			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="heading">

			
							<h1>Reviewer Information</h1>
		</div>

		
	
		
		<div id="row1012903" class="form-group">
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			<input type="hidden" class="rules-settings" value="null">
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												<div>
		<label class="form-label" for="input-field-1012903" id="label-field-1012903">
			Full Name			<span class="text-danger">*</span>		</label>
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<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012903]" id="input-field-1012903" value="">

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		<div id="row1012904" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;emailAddress&quot;:true,&quot;required&quot;:true}">
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												<div>
		<label class="form-label" for="input-field-1012904" id="label-field-1012904">
			Email			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012904]" id="input-field-1012904" value="">

	<p class="help-block"><small></small></p>
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		<div id="row1012905" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
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												<div>
		<label class="form-label" for="input-field-1012905" id="label-field-1012905">
			Position Title			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012905]" id="input-field-1012905" value="">

	<p class="help-block"><small></small></p>
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		<div id="row1012906" class="form-group">
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												<div>
		<label class="form-label" for="input-field-1012906" id="label-field-1012906">
			Department			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012906]" id="input-field-1012906" value="">

	<p class="help-block"><small></small></p>
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		<div id="row1012907" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text-input">

												<div>
		<label class="form-label" for="input-field-1012907" id="label-field-1012907">
			Institution			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012907]" id="input-field-1012907" value="">

	<p class="help-block"><small></small></p>
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			<input type="hidden" class="field-type" value="text-input">

												<div>
		<label class="form-label" for="input-field-1012908" id="label-field-1012908">
			Institution Address			<span class="text-danger">*</span>		</label>
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<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012908]" id="input-field-1012908" value="">

	<p class="help-block"><small></small></p>
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		<div id="row1012909" class="form-group">
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			<input type="hidden" class="field-type" value="text-input">

												<div>
		<label class="form-label" for="input-field-1012909" id="label-field-1012909">
			Institution City			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012909]" id="input-field-1012909" value="">

	<p class="help-block"><small></small></p>
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												<div>
		<label class="form-label" for="input-field-1123355" id="label-field-1123355">
			Institution Country			<span class="text-danger">*</span>		</label>
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<div class="field-error error-block" style="display: none;"></div>
			
								<input type="hidden" class="field-empty-value" name="data[form][1123355]">
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					<option value="AF">
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				Albania			</option>
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				Algeria			</option>
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				American Samoa			</option>
					<option value="AD">
				Andorra			</option>
					<option value="AO">
				Angola			</option>
					<option value="AI">
				Anguilla			</option>
					<option value="AQ">
				Antarctica			</option>
					<option value="AG">
				Antigua and Barbuda			</option>
					<option value="AR">
				Argentina			</option>
					<option value="AM">
				Armenia			</option>
					<option value="AW">
				Aruba			</option>
					<option value="AU">
				Australia			</option>
					<option value="AT">
				Austria			</option>
					<option value="AZ">
				Azerbaijan			</option>
					<option value="BS">
				Bahamas			</option>
					<option value="BH">
				Bahrain			</option>
					<option value="BD">
				Bangladesh			</option>
					<option value="BB">
				Barbados			</option>
					<option value="BY">
				Belarus			</option>
					<option value="BE">
				Belgium			</option>
					<option value="BZ">
				Belize			</option>
					<option value="BJ">
				Benin			</option>
					<option value="BM">
				Bermuda			</option>
					<option value="BT">
				Bhutan			</option>
					<option value="BO">
				Bolivia			</option>
					<option value="BA">
				Bosnia and Herzegovina			</option>
					<option value="BW">
				Botswana			</option>
					<option value="BV">
				Bouvet Island			</option>
					<option value="BR">
				Brazil			</option>
					<option value="IO">
				British Indian Ocean Territory			</option>
					<option value="BN">
				Brunei Darussalam			</option>
					<option value="BG">
				Bulgaria			</option>
					<option value="BF">
				Burkina Faso			</option>
					<option value="BI">
				Burundi			</option>
					<option value="KH">
				Cambodia			</option>
					<option value="CM">
				Cameroon			</option>
					<option value="CA">
				Canada			</option>
					<option value="CV">
				Cape Verde			</option>
					<option value="KY">
				Cayman Islands			</option>
					<option value="CF">
				Central African Republic			</option>
					<option value="TD">
				Chad			</option>
					<option value="CL">
				Chile			</option>
					<option value="CN">
				China			</option>
					<option value="CX">
				Christmas Island			</option>
					<option value="CC">
				Cocos (Keeling) Islands			</option>
					<option value="CO">
				Colombia			</option>
					<option value="KM">
				Comoros			</option>
					<option value="CG">
				Congo			</option>
					<option value="CK">
				Cook Islands			</option>
					<option value="CR">
				Costa Rica			</option>
					<option value="CI">
				Cote d'Ivoire			</option>
					<option value="HR">
				Croatia			</option>
					<option value="CU">
				Cuba			</option>
					<option value="CY">
				Cyprus			</option>
					<option value="CZ">
				Czech Republic			</option>
					<option value="DK">
				Denmark			</option>
					<option value="DJ">
				Djibouti			</option>
					<option value="DM">
				Dominica			</option>
					<option value="DO">
				Dominican Republic			</option>
					<option value="TL">
				East Timor			</option>
					<option value="EC">
				Ecuador			</option>
					<option value="EG">
				Egypt			</option>
					<option value="SV">
				El Salvador			</option>
					<option value="GQ">
				Equatorial Guinea			</option>
					<option value="ER">
				Eritrea			</option>
					<option value="EE">
				Estonia			</option>
					<option value="ET">
				Ethiopia			</option>
					<option value="FK">
				Falkland Islands (Malvinas)			</option>
					<option value="FO">
				Faroe Islands			</option>
					<option value="FJ">
				Fiji			</option>
					<option value="FI">
				Finland			</option>
					<option value="FR">
				France			</option>
					<option value="GF">
				French Guiana			</option>
					<option value="PF">
				French Polynesia			</option>
					<option value="TF">
				French Southern Territories			</option>
					<option value="GA">
				Gabon			</option>
					<option value="GM">
				Gambia			</option>
					<option value="GE">
				Georgia			</option>
					<option value="DE">
				Germany			</option>
					<option value="GH">
				Ghana			</option>
					<option value="GI">
				Gibraltar			</option>
					<option value="GR">
				Greece			</option>
					<option value="GL">
				Greenland			</option>
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				Grenada			</option>
					<option value="GP">
				Guadeloupe			</option>
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				Guam			</option>
					<option value="GT">
				Guatemala			</option>
					<option value="GN">
				Guinea			</option>
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				Guyana			</option>
					<option value="HT">
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				Heard and McDonald Islands			</option>
					<option value="HN">
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				Hong Kong			</option>
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				Hungary			</option>
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				Jordan			</option>
					<option value="KZ">
				Kazakhstan			</option>
					<option value="KE">
				Kenya			</option>
					<option value="KI">
				Kiribati			</option>
					<option value="KW">
				Kuwait			</option>
					<option value="KG">
				Kyrgyzstan			</option>
					<option value="LA">
				Lao People's Democratic Republic			</option>
					<option value="LV">
				Latvia			</option>
					<option value="LB">
				Lebanon			</option>
					<option value="LS">
				Lesotho			</option>
					<option value="LR">
				Liberia			</option>
					<option value="LY">
				Libya			</option>
					<option value="LI">
				Liechtenstein			</option>
					<option value="LT">
				Lithuania			</option>
					<option value="LU">
				Luxembourg			</option>
					<option value="MO">
				Macau			</option>
					<option value="MK">
				Macedonia			</option>
					<option value="MG">
				Madagascar			</option>
					<option value="MW">
				Malawi			</option>
					<option value="MY">
				Malaysia			</option>
					<option value="MV">
				Maldives			</option>
					<option value="ML">
				Mali			</option>
					<option value="MT">
				Malta			</option>
					<option value="MH">
				Marshall Islands			</option>
					<option value="MQ">
				Martinique			</option>
					<option value="MR">
				Mauritania			</option>
					<option value="MU">
				Mauritius			</option>
					<option value="YT">
				Mayotte			</option>
					<option value="MX">
				Mexico			</option>
					<option value="FM">
				Micronesia			</option>
					<option value="MD">
				Moldova			</option>
					<option value="MC">
				Monaco			</option>
					<option value="MN">
				Mongolia			</option>
					<option value="MS">
				Montserrat			</option>
					<option value="MA">
				Morocco			</option>
					<option value="MZ">
				Mozambique			</option>
					<option value="MM">
				Myanmar			</option>
					<option value="NA">
				Namibia			</option>
					<option value="NR">
				Nauru			</option>
					<option value="NP">
				Nepal			</option>
					<option value="NL">
				Netherlands			</option>
					<option value="AN">
				Netherlands Antilles			</option>
					<option value="NC">
				New Caledonia			</option>
					<option value="NZ">
				New Zealand			</option>
					<option value="NI">
				Nicaragua			</option>
					<option value="NE">
				Niger			</option>
					<option value="NG">
				Nigeria			</option>
					<option value="NU">
				Niue			</option>
					<option value="NF">
				Norfolk Island			</option>
					<option value="KP">
				North Korea			</option>
					<option value="MP">
				Northern Mariana Islands			</option>
					<option value="NO">
				Norway			</option>
					<option value="OM">
				Oman			</option>
					<option value="PK">
				Pakistan			</option>
					<option value="PW">
				Palau			</option>
					<option value="PS">
				Palestinian Territory			</option>
					<option value="PA">
				Panama			</option>
					<option value="PG">
				Papua New Guinea			</option>
					<option value="PY">
				Paraguay			</option>
					<option value="PE">
				Peru			</option>
					<option value="PH">
				Philippines			</option>
					<option value="PN">
				Pitcairn			</option>
					<option value="PL">
				Poland			</option>
					<option value="PT">
				Portugal			</option>
					<option value="QA">
				Qatar			</option>
					<option value="RE">
				Reunion			</option>
					<option value="RO">
				Romania			</option>
					<option value="RU">
				Russian Federation			</option>
					<option value="RW">
				Rwanda			</option>
					<option value="KN">
				Saint Kitts and Nevis			</option>
					<option value="LC">
				Saint Lucia			</option>
					<option value="VC">
				Saint Vincent and the Grenadines			</option>
					<option value="WS">
				Samoa			</option>
					<option value="SM">
				San Marino			</option>
					<option value="ST">
				Sao Tome and Principe			</option>
					<option value="SA">
				Saudi Arabia			</option>
					<option value="SN">
				Senegal			</option>
					<option value="CS">
				Serbia and Montenegro			</option>
					<option value="SC">
				Seychelles			</option>
					<option value="SL">
				Sierra Leone			</option>
					<option value="SG">
				Singapore			</option>
					<option value="SK">
				Slovakia			</option>
					<option value="SI">
				Slovenia			</option>
					<option value="SB">
				Solomon Islands			</option>
					<option value="SO">
				Somalia			</option>
					<option value="ZA">
				South Africa			</option>
					<option value="GS">
				South Georgia and The South Sandwich Islands			</option>
					<option value="KR">
				South Korea			</option>
					<option value="SS">
				South Sudan			</option>
					<option value="ES">
				Spain			</option>
					<option value="LK">
				Sri Lanka			</option>
					<option value="SH">
				St. Helena			</option>
					<option value="PM">
				St. Pierre and Miquelon			</option>
					<option value="SD">
				Sudan			</option>
					<option value="SR">
				Suriname			</option>
					<option value="SJ">
				Svalbard and Jan Mayen Islands			</option>
					<option value="SZ">
				Swaziland			</option>
					<option value="SE">
				Sweden			</option>
					<option value="CH">
				Switzerland			</option>
					<option value="SY">
				Syria			</option>
					<option value="TW">
				Taiwan			</option>
					<option value="TJ">
				Tajikistan			</option>
					<option value="TZ">
				Tanzania			</option>
					<option value="TH">
				Thailand			</option>
					<option value="TG">
				Togo			</option>
					<option value="TK">
				Tokelau			</option>
					<option value="TO">
				Tonga			</option>
					<option value="TT">
				Trinidad and Tobago			</option>
					<option value="TN">
				Tunisia			</option>
					<option value="TR">
				Turkey			</option>
					<option value="TM">
				Turkmenistan			</option>
					<option value="TC">
				Turks and Caicos Islands			</option>
					<option value="TV">
				Tuvalu			</option>
					<option value="UG">
				Uganda			</option>
					<option value="UA">
				Ukraine			</option>
					<option value="AE">
				United Arab Emirates			</option>
					<option value="GB">
				United Kingdom			</option>
					<option value="US">
				United States			</option>
					<option value="UM">
				United States Minor Outlying Islands			</option>
					<option value="UY">
				Uruguay			</option>
					<option value="UZ">
				Uzbekistan			</option>
					<option value="VU">
				Vanuatu			</option>
					<option value="VA">
				Vatican			</option>
					<option value="VE">
				Venezuela			</option>
					<option value="VN">
				Viet Nam			</option>
					<option value="VG">
				Virgin Islands (British)			</option>
					<option value="VI">
				Virgin Islands (U.S.)			</option>
					<option value="WF">
				Wallis and Futuna Islands			</option>
					<option value="EH">
				Western Sahara			</option>
					<option value="YE">
				Yemen			</option>
					<option value="ZM">
				Zambia			</option>
					<option value="ZW">
				Zimbabwe			</option>
			</select>

	<p class="help-block"><small></small></p>
		</div>

		
	
		
		<div id="row1012910" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="state-select">

												<div>
		<label class="form-label" for="input-field-1012910" id="label-field-1012910">
			State					</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
								<input type="hidden" class="field-empty-value" name="data[form][1012910]">
	<select class="form-control" name="data[form][1012910]" id="input-field-1012910">
		<option value=""></option>
					<option value="US-AL">
				Alabama			</option>
					<option value="US-AK">
				Alaska			</option>
					<option value="US-AZ">
				Arizona			</option>
					<option value="US-AR">
				Arkansas			</option>
					<option value="US-CA">
				California			</option>
					<option value="US-CO">
				Colorado			</option>
					<option value="US-CT">
				Connecticut			</option>
					<option value="US-DE">
				Delaware			</option>
					<option value="US-DC">
				District Of Columbia			</option>
					<option value="US-FL">
				Florida			</option>
					<option value="US-GA">
				Georgia			</option>
					<option value="US-HI">
				Hawaii			</option>
					<option value="US-ID">
				Idaho			</option>
					<option value="US-IL">
				Illinois			</option>
					<option value="US-IN">
				Indiana			</option>
					<option value="US-IA">
				Iowa			</option>
					<option value="US-KS">
				Kansas			</option>
					<option value="US-KY">
				Kentucky			</option>
					<option value="US-LA">
				Louisiana			</option>
					<option value="US-ME">
				Maine			</option>
					<option value="US-MD">
				Maryland			</option>
					<option value="US-MA">
				Massachusetts			</option>
					<option value="US-MI">
				Michigan			</option>
					<option value="US-MN">
				Minnesota			</option>
					<option value="US-MS">
				Mississippi			</option>
					<option value="US-MO">
				Missouri			</option>
					<option value="US-MT">
				Montana			</option>
					<option value="US-NE">
				Nebraska			</option>
					<option value="US-NV">
				Nevada			</option>
					<option value="US-NH">
				New Hampshire			</option>
					<option value="US-NJ">
				New Jersey			</option>
					<option value="US-NM">
				New Mexico			</option>
					<option value="US-NY">
				New York			</option>
					<option value="US-NC">
				North Carolina			</option>
					<option value="US-ND">
				North Dakota			</option>
					<option value="US-OH">
				Ohio			</option>
					<option value="US-OK">
				Oklahoma			</option>
					<option value="US-OR">
				Oregon			</option>
					<option value="US-PA">
				Pennsylvania			</option>
					<option value="US-PR">
				Puerto Rico			</option>
					<option value="US-RI">
				Rhode Island			</option>
					<option value="US-SC">
				South Carolina			</option>
					<option value="US-SD">
				South Dakota			</option>
					<option value="US-TN">
				Tennessee			</option>
					<option value="US-TX">
				Texas			</option>
					<option value="US-UT">
				Utah			</option>
					<option value="US-VT">
				Vermont			</option>
					<option value="US-VA">
				Virginia			</option>
					<option value="US-WA">
				Washington			</option>
					<option value="US-WV">
				West Virginia			</option>
					<option value="US-WI">
				Wisconsin			</option>
					<option value="US-WY">
				Wyoming			</option>
			</select>

	<p class="help-block"><small></small></p>
		</div>

		
	
		
		<div id="row1012911" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text-input">

												<div>
		<label class="form-label" for="input-field-1012911" id="label-field-1012911">
			Institution Zipcode			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012911]" id="input-field-1012911" value="">

	<p class="help-block"><small></small></p>
		</div>

		
	
		
		<div id="row1012912" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text-input">

												<div>
		<label class="form-label" for="input-field-1012912" id="label-field-1012912">
			Telephone Number			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<input type="text" class="form-control" name="data[form][1012912]" id="input-field-1012912" value="">

	<p class="help-block"><small></small></p>
		</div>

		
	
		
		<div id="row1012913" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="heading">

			
							<h1>Conflict-of-Interests and Confidentiality Statement for PRSTRT Reviewers</h1>
		</div>

		
	
		
		<div id="row1012914" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text">

			
									<p></p><p><strong>Your Potential Conflicts of Interests</strong>:  Your designation as a reviewer for the Puerto Rico Science, Technology and Research Trust (PRSTRT) requires that you be aware of potential conflict of interest (COI) situations that may arise. Please read the examples of potentially biasing affiliations <a class="external-link" href="https://drive.google.com/file/d/1A_RMHrcCShXF0_c_EE_suEelim6epPw2/view?usp=sharing" target="_blank" rel="noreferrer noopener">here</a>. As a PRSTRT reviewer, you will be asked to evaluate applications and letters of support from individuals outside of the Trust. You may have a conflict (or present the appearance of conflict) with regard to providing unbiased assessments for one or more of the evaluations assigned to you. Should any conflict or appearance of conflict arise, you must bring the matter to the attention of the Grants Program.</p><p></p>
			</div>

		
	
		
		<div id="row1012915" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text">

			
									<p></p><p><strong>No Use of “Insider” Information</strong>:  If your designation gives you access to information not generally available to the public, you must not use that information for your personal benefit or make it available for the personal benefit of any other individual or organization. This is to be distinguished from the entirely appropriate benefit of learning more about the Trust’s programs, learning from other panel members, or becoming better acquainted with the state of a given discipline.</p><p></p>
			</div>

		
	
		
		<div id="row1012916" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text">

			
									<p></p><p><strong>Your Obligation to Maintain the Confidentiality of Proposals, Applicants, and Discussions</strong>:  The PRSTRT receives proposals and information from external applicants in confidence. The applications and proposals, identity of the applicants, associated materials made available to reviewers, information and materials related to the reviews, reviewers’ evaluations, and discussion that take place during review meetings are strictly confidential and must not be disclosed to or discussed with any individual who has not been officially designated to participate in the review process. For this reason, you must not copy, quote, or otherwise use or disclose to anyone, including your graduate students or post-doctoral or research associates, any material you are asked to review or details about the discussions during the review process. If you believe a colleague can make a substantial contribution to the grant program staff before disclosing the name of any applicant or principal investigator or any materials or information related to the proposal or progress report. If you believe there has been a breach of confidentiality, you must notify your PRSTRT grant program staff immediately. Any breach of confidentiality could subject you to sanctions and will automatically disqualify you from being considered in the future for funding opportunities, panels, programs, or other roles with the Trust.</p><p></p>
			</div>

		
	
		
		<div id="row1012917" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text">

			
									<p></p><p><strong>Confidentiality of the Review Process and Reviewer Names</strong>:  Please be careful not to disclose any identifiable information about yourself in your review documents and respect the confidentiality of other reviewers. Do not disclose their identities, the relative assessments or rankings of proposals by a peer review panel, or other details about the peer review of proposals. Unauthorized disclosure of any confidential information could subject you to sanctions.</p><p></p>
			</div>

		
	
		
		<div id="row1012919" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="heading">

			
							<h1>Your certification:</h1>
		</div>

		
	
		
		<div id="row1015944" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="checkbox">

												<div>
		<label class="form-label" for="input-field-1015944" id="label-field-1015944">
			I have read the list of affiliations and relationships that could present a conflict of interest or the appearance of a conflict of interest and require me to recuse myself from reviewing specific individuals or institutions. I understand that I must contact a PRSTRT representative if a conflict exists or arises during my service.			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<p class="help-block" style="margin: 0 0 4px;">
		<small></small>
	</p>

		<input type="hidden" class="field-empty-value" name="data[form][1015944]">

	<div aria-describedby="label-field-1015944">
					<div class="checkbox">
				<label class="checkbox-label">
					<input type="checkbox" value="I agree" name="data[form][1015944][]">
					<span>
						I agree					</span>
				</label>
			</div>
			</div>
		</div>

		
	
		
		<div id="row1015945" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="checkbox">

												<div>
		<label class="form-label" for="input-field-1015945" id="label-field-1015945">
			I will refrain from using any insider information I may come in contact with for personal gain or benefit or for the personal gain or benefit of another individual or organization.			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<p class="help-block" style="margin: 0 0 4px;">
		<small></small>
	</p>

		<input type="hidden" class="field-empty-value" name="data[form][1015945]">

	<div aria-describedby="label-field-1015945">
					<div class="checkbox">
				<label class="checkbox-label">
					<input type="checkbox" value="I agree" name="data[form][1015945][]">
					<span>
						I agree					</span>
				</label>
			</div>
			</div>
		</div>

		
	
		
		<div id="row1015946" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="checkbox">

												<div>
		<label class="form-label" for="input-field-1015946" id="label-field-1015946">
			I will maintain the confidentiality of the review proceedings and all associated materials and will not divulge or use any confidential information, as described above, that I may become in contact with or aware of during my service.			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<p class="help-block" style="margin: 0 0 4px;">
		<small></small>
	</p>

		<input type="hidden" class="field-empty-value" name="data[form][1015946]">

	<div aria-describedby="label-field-1015946">
					<div class="checkbox">
				<label class="checkbox-label">
					<input type="checkbox" value="I agree" name="data[form][1015946][]">
					<span>
						I agree					</span>
				</label>
			</div>
			</div>
		</div>

		
	
		
		<div id="row1015947" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="checkbox">

												<div>
		<label class="form-label" for="input-field-1015947" id="label-field-1015947">
			I understand my identity as a reviewer of specific proposals will be kept confidential to the maximum extent possible, except that copies of written reviews that I submit will be sent to the principal investigator(s) without my name and affiliation. I will maintain the identity of other reviewers confidential in turn.			<span class="text-danger">*</span>		</label>
	</div>


<div class="field-error error-block" style="display: none;"></div>
			
							<p class="help-block" style="margin: 0 0 4px;">
		<small></small>
	</p>

		<input type="hidden" class="field-empty-value" name="data[form][1015947]">

	<div aria-describedby="label-field-1015947">
					<div class="checkbox">
				<label class="checkbox-label">
					<input type="checkbox" value="I agree" name="data[form][1015947][]">
					<span>
						I agree					</span>
				</label>
			</div>
			</div>
		</div>

		
	
		
		<div id="row1012918" class="form-group">
			<input type="hidden" class="validation-settings" value="[]">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="text">

			
									<p>If the PRSTRT determines that a situation involved a bona fide breach of confidentiality, use of insider information, or lack of disclosure of conflict of interest in the peer review process, it may undertake remedial steps and in some cases sanctions including, but not limited to: Notifying the reviewer in question; Terminating the reviewer's term;  Prohibiting the reviewer from submitting proposals to the PRSTRT or from participating in other of the PRSTRT’s programs in the future;  Preventing the reviewer from serving in the future as a panelist, reviewer, or in another capacity with the PRSTRT.</p>
			</div>

		
	
		
		<div id="row1012920" class="form-group">
			<input type="hidden" class="validation-settings" value="{&quot;required&quot;:true}">
			<input type="hidden" class="rules-settings" value="null">
			<input type="hidden" class="field-type" value="checkbox">

												<div>
		<label class="form-label" for="input-field-1012920" id="label-field-1012920">
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