Conflict Of Interest Disclosure Form printable pdf download

Conflict of Interest Disclosure Form

In completing this form about my activities for the upcoming academic year (20_____-20_____), I affirm

that I have read and understand the policies of Western Carolina University regarding Conflict of

Interest. To the best of my knowledge, the information provided by me is true.

Employee Name (print): _________________________________________92#______________________

Signature of Employee: ______________________________________________ Date:_________________

Department: _________________________________________________________________________________

A Conflict of Interest relates to situations where

A Financial Interest is defined as: (i) payment for

financial or other personal matters may compromise,

services not inclusive of WCU base salary; (ii) equity

may involve the potential for compromising, or may

or other ownership interest in publicly or non-publicly

have the appearance of compromising an

traded entities; or (iii) intellectual property rights and

employee’s objectivity in fulfilling his/her University

interests upon receipt of income related to such

duties or responsibilities.

rights and interest held by employee or family

members.

Check all that apply:

☐ I have no Conflict of Interest activities to report. (If you check this item, this form

may now be submitted to your Department Head or Director)

☐ I have a potential Conflict of Interest to report.*

☐ I have a Financial Interest that may affect decision making with respect to my

employment.*

☐ I have a significant Financial Interest related to PHS-funded research.*

☐ A member of my immediate family (i.e., spouse and dependent children) has a

personal Financial Interest in an activity that may affect decision making with

respect to my employment.*

☐ A member of my immediate family (i.e., spouse and dependent children) has a

relationship, commitment, or activity that may present a Conflict of Interest with my

employment at Western Carolina University.*

☐ I, or a member of my immediate family (i.e., spouse and dependent children),

have received reimbursed or sponsored travel, related to my institutional

responsibilities.*

*If you have disclosed a potential Conflict of Interest or a Financial Interest

held by you or an immediate family member, you must describe each potential

Conflict of Interest or Financial Interest on an attached document.

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Conflict Of Interest Disclosure Form