Conflict of Interest – Faculty – Burrell College of Osteopathic Medicine Forms

Name:*

First Last

Employee ID:*

Title:*

Department:*

This conflict of interest form contains information that may have direct bearing on your employment and completing this form is a condition of your employment. This form will be stored by The Office of Human Resources and considered confidential. The information submitted on this form is only available to individuals duly charged with the responsibility for review and may be released only in accordance with and as required by federal or state law; or regulations; or lawful court order.

Are you engaged in any other employment or consulting (including self-employment) outside of the institution (Burrell College)?*

Yes
No

Employees Comments:*

Please include the following in the space provided below: name of entity/activity; location; services/products offered; your relationship to the entity; anticipated dates of activity; estimated hours per week (if during work hours indicate whether annual leave will be take); and indicate any fees or gifts received, expenses paid or donations of goods or services with an aggregated value of $100 or greater in the previous 12-month period.

Do you receive compensation including but not limited to, consulting fees or honoraria (in excess of $500) for professional activities such as teaching at another institution or employment as an expert witness? Please consider that actual or perceived conflicts of interest or commitment in sponsored activities generally arise when an investigator of family member has a significant financial interest in, or a consulting arrangement with, a private business concern, or other organization that is or may be affected by the sponsored activity.*

Yes
No

Employee Comments:*

If yes, please include in the section below, the following: name of entity or nature of activity, compensation received including gifts, donations or services.

Do you serve on the board of directors or an advisory board of a business from which you or a family member receives project support or with which the institution has a contractual relationship?*

Yes
No

Employee Comments:*

If yes, please explain below.

Have you or a family member received gifts, favors or gratuities with an aggregated value of $100 or greater in the previous 12-month period, excluding meals and text books, from a person or business that you know to be doing business with or attempting to do business with the institution?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you or a family member engaged in an outside business or employment relationship with institution employees and/or students?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you engaged in any community service, contractual relationship, or hold a significant financial interest which may create a conflict of interest between the interests and the performance of your public responsibilities and obligation to Burrell College, including time commitments?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you or a family member a candidate for an elected or appointed public office? Are you or a family member serving as an elected or appointed public official (e.g. Board, commission or a position in state)?*

Yes
No

Employee Comments:*

If yes, please explain below.

Do you receive compensation from externally-sponsored projects or activities?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you or a family member engaged in sponsored activities that include consulting, travel, contractual activities, have significant financial interest in, receive a financial gain/benefit from a business entity that does business with the institution or provides services similar to the institution?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you or a family member engaged in any outside activities (i.e. outside ventures including publicly held corporations) or in which you or a family member holds significant financial interest more than $5,000; or holds equity interest (e.g. stock, stock option, or other ownership interest) exceeding $5,000, which are required to be reported under federal contract and grant regulations?*

Yes
No

Employee Comments:*

If yes, please explain below.

Do you hold any intellectual property rights and/or participate in any outside activity in which you are required to waive rights to intellectual property?*

Yes
No

Employee Comments:*

If yes, please explain below.

Are you or a family member engaged in outside activities in which you utilize institution facilities, equipment and/or services?*

Yes
No

Employee Comments:*

If yes, in the section provided below, please include the following: describe the activity and provide details regarding the use of the institution resources (e.g. % of use, times per year, etc.) including the details of arrangements for reimbursement of usage.

Do your Burrell College activities, including teaching and research, require use of institution books, supplies, equipment or other instructional materials created or published by you or by an entity in which you or a family member has a significant financial interest?*

Yes
No

Employee Comments:*

If yes, please explain below

Are you or a family member engaged in any activity, not otherwise reported above, which you or a member of the public could reasonably conclude may create an actual or perceived conflict of interest or time commitment?*

Yes
No

Employee Comments:*

If yes, please explain below

Employee Signature:*

Date:*