CONFIDENTIAL
2007 - Conflict of Interest and Commitment Disclosure Statement for Selected Staff - 2007
Name:
Title:
Department and Box Number:
Supervisor’s Name:
Secondary Signatory:
Assigned Senior Administrator:
Read the University’s Conflict of Interest and Commitment Policy and its related guidelines before completing this form.
1. List the names of all entities in which you have a significant financial interest1 that you know do business,
indirectly or directly, with Brown:
2. List family members2 who are either employed by the University or are students at the University:
Name Relationship to you Position at Brown
3. If you have influence over business relationships between Brown and any family members or associates,3
describe these relationships.
4. Provide information on your service and professional engagements when you serve in a position of
responsibility, such as an officer or a member of a board of directors.
1
The University’s Conflict of Interest and Commitment Policy defines two types of significant financial interest:
a) Receipt of anything of monetary value from a single source exceeding $5,000 annually. Examples include salary,
royalties, gifts, and payments for services including consulting fees and honoraria. Excluded are inheritances, and
income from debt obligations of the US, state, or local governments, certificates of deposit, blind trusts, and
broadly diversified mutual funds and brokerage accounts managed by third parties.
b) Ownership of an equity interest exceeding the lesser of 5% or $100,000 in any single entity, excluding US, state,
or local government debt obligations, certificates of deposit, blind trusts, and broadly diversified mutual funds and
brokerage accounts managed by third parties.
2
The University’s Conflict of Interest and Commitment Policy defines a family member as a spouse, domestic partner,
parent, child, sibling, or member of your household.
3
The University’s Conflict of Interest and Commitment Policy defines an associate as any individual or organization
with whom you have a close personal or business relationship such that a benefit to the associate could be construed as a
personal favor by you and/or an indirect benefit to you personally.
5. List all gifts or favors valued at $50 or more from a single source in a single year (excluding business
meals and professional printed matter) if given by an entity or person employed by, conducting business
with, or likely to conduct business with the University (e.g., a vendor, sponsor, donor, student, or
student’s parent).
Source Item and Value
6. The previous questions ask you to describe your affiliations and activities. Are there any actual or
,
potential conflicts of interest or commitment that you have as a result of these or other interests activities,
or relationships? ___ Yes (if yes, describe below or on attached sheets)
___ No
I affirm, as an employee of Brown University, that I have read the University’s Conflict of
Interest and Commitment Policy and its related guidelines, and I agree to comply with the
Policy and to report potential or actual conflicts to my supervisor when they arise.
_______________________________________________________
Employee’s signature Date
Forward your signed disclosure form to your supervisor.
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I have reviewed this form and discussed the contents with the employee. I have determined that (check one):
a. ____There are no activities or affiliations requiring disclosure and, therefore, no potential conflicts.
b. ____The activities and/or affiliations disclosed do not pose potential conflicts.
c. ____The activities and/or affiliations disclosed do pose potential conflicts and therefore I have attached a
plan for managing the conflicts.
_______________________________________________________
Supervisor’s signature Date
If b. or c. above have been checked, a secondary reviewer’s signature is required (see below). The secondary reviewer
shall be the assigned senior administrator for the employee or, when the assigned senior administrator is also the
employee’s supervisor, the assigned senior administrator’s supervisor. The same person cannot sign both as an
employee’s supervisor and as his or her secondary reviewer.
If a .is checked, forward the signed original to the assigned senior administrator for this employee who will be
responsible for forwarding to Human Resources..
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I have reviewed these disclosures and any management plans that are warranted, and I consider them adequate
to address the substance and/or the appearance of any conflict that could arise from the disclosed interests,
activities, or relationships.
_______________________________________________________
Secondary reviewer’s signature Date
Forward the signed original to the assigned senior administrator for this employee.
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Assigned senior administrators: Record form’s completion and forward it to Human Resources, Box 1879.