Conflict Of Interest Disclosure Form (Page 2 of 2) in pdf

Conflict Of Interest Disclosure Form Page 2

Review by Department Head or Director:

After reviewing the information provided above and the attachments, the reviewing official should

determine if there is a violation of the Conflict of Interest policy of Western Carolina University.

If a violation of the Conflict of Interest policy is found, a Conflict of Interest management plan shall be

developed and approved by the Dean or Vice Chancellor and the Conflict of Interest Panel.

Conflict of Interest present: ☐ Yes

☐ No

Name (print): ________________________________________________________________________________

Signature:

Date:

Review by Dean or Vice Chancellor:

Conflict of Interest present: ☐ Yes

☐ No

 If yes, do you approve the proposed Management Plan: ☐ Yes

☐ No

Name (print): ________________________________________________________________________________

Signature:

Date:

Review by Conflict of Interest Panel*:

*Only necessary if a Conflict of Interest is present. To be completed by the chair after the panel has

reviewed the proposed Management Plan.

Does the panel approve the proposed Management Plan: ☐ Yes

☐ No

Name (print): ________________________________________________________________________________

Signature:

Date:

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Conflict Of Interest Disclosure Form Page 2