Disclosure of Conflict of Interest Form Incorporating management strategy Employee [or insert other title] Name: Role: Date of disclosure: 1. Will any of these Me, my immediate Who? persons be perceived family to, potentially, or Yes / No actually gain a benefit as a result of my Companies / trusts / Which? decision or action? associations Please circle Yes / No Describe and identify the actual, potential or perceived benefit. Pecuniary or Describe the interest of 2. my agency that the actual, potential or perceived benefit conflicts with. How do I propose to 3. manage the actual, potential or perceived conflict of interest?
Disclosure of Conflict of Interest Form Incorporating management strategy Employee [or insert other title] Name: Role: Date of disclosure: 1. Will any of these persons be perceived to, potentially, or actually gain a benefit as a result of my decision or action? Please circle Me, my immediate family Yes / No Who? Companies / trusts / associations Yes / No Which? Describe and identify the actual, potential or perceived benefit. Pecuniary or 2. Describe the interest of my agency that the actual, potential or perceived benefit conflicts with. 3. How do I propose to manage the actual, potential or perceived conflict of interest?
Disclosure_of_Conflict_of_Interest_-_CoI_form_-_template.docx