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Run: Conflict of Interest Disclosure Form

A Conflict of Interest Disclosure Form for reporting outside employment, family relationships, financial interests, gifts, and use of company resources. Use ...

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Submitter Information

Full Name (required)

Job Title (required)

Department (required)

Work Email (required)

Employee ID

Optional. Only collect if needed for internal routing or audit trail.

Disclosure Type

What are you disclosing? (required)

Brief Summary (required)

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? (required)

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? (required)

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? (required)

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? (required)

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? (required)

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? (required)

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? (required)

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? (required)

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. (required)

Yes No N/A

Attestation (required)

By signing, you confirm that the information provided is true and complete to the best of your knowledge.

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Email (required)

Your name (optional)

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