Annex C: Template Declaration of gifts and hospitality Recipient Position Date Date of Details of Estimated Supplier / Details of Details of the Declined Reason for Name of Receipt (if Gift / Value Offeror: previous offers officer reviewing or Accepting Comments Offer applicable) Hospitality Name and or Acceptance and approving the Accepted? or Nature of by this Offeror/ declaration made Declining Business Supplier and date The information submitted will be held by the CCG for personnel or reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and in the case of making staff’ (as defined in the ‘decision statutory guidance on managing conflicts of interest for CCGs), may be published in registers that the CCG holds. I confirm that the information provided is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result. Decision making staff should be aware that the information provided in this form will be added to the CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s website. Decision making staff must make any third party whose personal data they are providing in this form aware that the personal data will held in hardcopy for inspection by the public and published on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the CCG’s website. If you are not sure whether you are a making’ member of staff, please speak to your line manager before completing this form. ‘decision Signed: Date: Signed: Position: Date: (Line Manager or a Senior CCG Manager) Please return to <insert name/contact details for team or individual in CCG nominated to provide advice, support, and guidance on how conflicts of interest should be managed, and administer associated administrative processes>
Annex C: Template Declaration of gifts and hospitality Recipient Name Position Date of Offer Date of Receipt (if applicable) Details of Gift / Hospitality Estimated Value Supplier / Offeror: Name and Nature of Business Details of previous offers or Acceptance by this Offeror/ Supplier Details of the officer reviewing and approving the declaration made and date Declined or Accepted? Reason for Accepting or Declining Comments The information submitted will be held by the CCG for personnel or reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and in the case of ‘decision making staff’ (as defined in the statutory guidance on managing conflicts of interest for CCGs), may be published in registers that the CCG holds. I confirm that the information provided is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, professional regulatory or internal disciplinary action may result. Decision making staff should be aware that the information provided in this form will be added to the CCG’s registers which are held in hardcopy for inspection by the public and published on the CCG’s website. Decision making staff must make any third party whose personal data they are providing in this form aware that the personal data will held in hardcopy for inspection by the public and published on the CCG’s website and must inform the third party that the CCG’s privacy policy is available on the CCG’s website. If you are not sure whether you are a ‘decision making’ member of staff, please speak to your line manager before completing this form. Signed: Date: Signed: Position: Date: (Line Manager or a Senior CCG Manager) Please return to <insert name/contact details for team or individual in CCG nominated to provide advice, support, and guidance on how conflicts of interest should be managed, and administer associated administrative processes>
coi-annex-c-jul-17.docx