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3 Q Q Q Q Q $ u u u P Y u )! > B V $ " w% Q b b b Q Q b F Q Q b V D @ P u F 0 )! x M& M& M& Q b b b b b b b b b b )! b b b b M& b b b b b b b b b : APPENDIX A - CONFLICT OF INTEREST POLICY
FACULTY DISCLOSURE FORM
Each employee of the University is required by Board of Governors policy to submit this disclosure form describing the particulars of potential conflicts of interest (e.g. see Section 2.7.1.1.7, Faculty Handbook, adopted by (then) SBA 4-19-88). Disclosure forms (fully executed with signatures) and any management plans to remove conflicts shall be permanently maintained in the employees official personnel file.
Instructions to faculty:
Prior to completing form, review Faculty Handbook Section 2.7.1.1, especially definitions & examples in 2.7.1.1.2 & 2.7.1.1.3.
Submit completed form to your department chair on or before October 1 of each year.
Submit an updated form to your department chair prior to engaging in activities that have the potential for interpretation as a conflict of interest at any other time during the calendar year.
Respondent (required section)
Name:
Title:
Phone:
Department\Program:
College:
Check one:
Annual Disclosure
Updated Disclosure
I have reviewed the policy and understand that I must indicate any and all activities or projects, currently in progress or planned, which have the potential for interpretation as a conflict of interest, and:
a memorandum stating particulars of all such activities and projects is attached.
I am in compliance with the Conflict of Interest policy.
I have nothing to disclose.
Signature Date
Department Chair / Immediate Supervisor (required section)
I have reviewed the signed statement above and the attached memorandum (if any) and,
in my opinion, no conflict of interest exists.
have judged that a potential conflict exists.
have attached a memorandum recommending action that will eliminate that potential.
Signature Date
Dean / Director / Vice President (This section required only if a potential conflict has been identified.)
I have reviewed the signed statements above and the attached memoranda and,
in my opinion, no conflict of interest exists.
I concur with the action recommended by the supervisor/chair.
a written agreement with the respondent is attached which, I believe will eliminate and avoid any conflict.
agreement with the respondent has not been reached. The issue is referred to the Provost.
Signature Date
Provost (This section required only if a potential conflict has been identified.)
I have reviewed the signed statements above and the attached memoranda and,
in my opinion, no conflict of interest exists.
the attached agreement with the respondent is accepted.
a written decision is appended and a copy submitted to the respondent.
Signature Date
Version 1.1 (updated September 2013)
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