Conflict of Interest Disclosure Form

Collects disclosures of outside relationships, financial interests, and activities that may create a conflict of interest, including requests for pre-approval where required.

Submitter Information

• Full Name
• Job Title
• Department
• Work Email
• Employee ID
  Optional. Only collect if needed for internal routing or audit trail.

Disclosure Type

• What are you disclosing?
• Brief Summary
  Describe the situation in enough detail for an initial review. Do not include unnecessary personal data.
• Is this a new disclosure or an update to a previous one?
• Previous Disclosure Reference
  Enter the prior case number or reference if you are updating an existing disclosure.

Outside Relationships and Activities

• Do you have outside employment or consulting work?
• Outside Employment Details
  Include employer/client name, role, dates, and whether the work overlaps with your company responsibilities.
• Do you serve on a board, advisory group, or committee?
• Board or Advisory Service Details
  Provide the organization name, your role, compensation if any, and any relationship to company business.
• Do you have a family or personal relationship that could affect business decisions?
• Relationship Details
  Identify the relationship and the business area involved. Avoid unnecessary personal details.

Financial Interests

• Do you or an immediate family member have a financial interest in a vendor, customer, competitor, or partner?
• Type of Financial Interest
• Financial Interest Details
  Describe the entity, your relationship, and why it may create a conflict. Do not include account numbers or other unnecessary PII.
• Approximate Ownership Percentage
  Enter an estimate if applicable.

Gifts, Entertainment, and Use of Resources

• Have you received or offered gifts, entertainment, travel, or hospitality related to company business?
• Gift or Hospitality Details
  Include who provided it, approximate value, date, and business context.
• Have you used company resources, time, or information for outside activities?
• Company Resources Use Details
  Describe the resource used and the circumstances. Include only information needed for review.

Pre-Approval Request and Attestation

• Does this activity require pre-approval before you proceed?
• Pre-Approval Request
  Explain what you want to do, the expected timing, and any steps already taken.
• I acknowledge that I have read and understand the organization's conflict of interest policy.
• Attestation
  By signing, you confirm that the information provided is true and complete to the best of your knowledge.