Form Com020 - Conflict Of Interest Disclosure Statement Template - Department Of Behavioral Health, San Bernardino County
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2San Bernardino County
Department of Behavioral Health
CONFLICT OF INTEREST DISCLOSURE STATEMENT
Initial Disclosure
Annual Disclosure
Update Disclosure
Pursuant with California Government Code Sections 1125-1127, all Department of Behavioral Health (DBH)
staff must complete the following form. The Standard Practice Manual contains the DBH Policy titled Conflict of
Interest that states DBH’s rules regarding outside employment and affiliations that may conflict with your
county position. According to this policy, you are required to disclose in writing any outside employment or
activity regardless of compensation, which relates to your county duties or to the functions and responsibilities
of your department, office or agency.
PLEASE TYPE OR LEGIBLY PRINT RESPONSES
Employee Name __________________________________________________________________________
DBH Job Title _______________________________________________ Employee Number _____________
DBH Program Name __________________________________________ Phone Number ________________
I AM NOT EMPLOYED OR AFFILIATED WITH ANY BEHAVIORAL HEALTH ORGANIZATIONS
AND/OR ALCOHOL AND DRUG PROGRAMS OTHER THAN SAN BERNARDINO COUNTY DBH.
Outside Employment/Affiliations. Please list below all current employment or affiliations outside of DBH.
Indicate self-employment, if applicable.
Employer/Organization Name __________________________________________________________
1.
Date Employment Commenced ________________________
Phone Number ______________________
Address ________________________________________________________________________________
________________________________________________________________________________________
Type of service/organization _________________________________________________________________
Position Title _____________________________________________________________________________
Work schedule and duties performed (be specific) ________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Do(es) you/the agency serve Medi-Cal clients? Yes ☐ No ☐
Indicate client population served: Children ☐
Transitional Age Youth ☐ Adults ☐
Older Adults ☐
Indicate services you/the agency provide(s): Mental Health ☐ Alcohol and Drug Services ☐ Not applicable ☐
Briefly describe how clients are referred to you/the agency. ________________________________________
________________________________________________________________________________________
2. Employer/Organization Name __________________________________________________________
Date Employment Commenced ________________________
Phone Number ______________________
Address ________________________________________________________________________________
________________________________________________________________________________________
Type of service/organization _________________________________________________________________
COM020 (03/16)
Compliance
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