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					                                      Annual Conflict of Interest Disclosure Survey

 All Members of the Notre Dame community are committed to identifying and avoiding situations and activities that
 constitute a Conflict of Interest in the execution of their duties for the University. Furthermore, activities, situations, and
 relationships that might create the perception of or potential for a Conflict of Interest must be identified and managed
 appropriately.
 An actual Conflict of Interest arises in a situation where financial or other personal or professional considerations
 compromise an individual’s objectivity, professional judgment, professional integrity, and/or ability to perform his or her
 responsibilities to the University. In addition to situations that clearly give rise to an actual Conflict of Interest, individuals
 are cautioned also to consider gray areas that might create the perception of or the potential for a Conflict of Interest.
 Perceived or potential Conflicts of Interest can be said to exist in situations where an individual member of the University
 community, a member of the individual’s family, or a close personal relation has financial interests, personal relationships,
 or professional associations with an individual, individuals, or outside organization, such that his or her activities within the
 University could appear to be biased against the University by that interest or relationship.
 Before filling out this Disclosure Survey, please read the University Conflict of Interest Policy. Questions about an activity
 that may represent a Conflict of Interest should be referred to a supervisor or unit head.


MEMBER INFORMATION
 Name:
 School/Department:
 Position Title:
 University ID No.:
 NetID:
 Campus Phone No.:
 E-mail address:



1. Are you in a position to influence or commit University resources? For example, can you impact
decision-making or offer advice on where to purchase items for your office or academic group?
        NO (Skip questions 2-6, and sign, date, and submit Survey to Reviewer)
        YES (Answer questions 2-6, and sign, date, and submit Survey to Reviewer)

2. Do you have a relationship with any sponsor, vendor, contractor, or business entity with which the
University does business or is likely to do business, for which you have an opportunity to influence a
related University decision? Include the relationship of any family member or close friend (indicate entity’s
name and relationship to you or your family/friend):




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3. Do you have an economic interest, including consulting work, in any sponsor, vendor, contractor, or
business entity with which the University does business with or is likely to do business, for which you
have an opportunity to influence a related University decision? Include the economic interest of any family
member or close friend (indicate the entity’s name, the annual amount of any profits or compensation, market
value of any equity, and any intellectual property rights):




4. Are you involved in any non-University income-producing activities involving University students, staff,
or facilities?




5. Are you involved in any other activity that could result in a financial, personal, or professional benefit
for you, a family member, or close friend, as related to any personal influence you may have in University
operations or business decisions?




6. Are you involved in any other activity, financial or otherwise, that could have the appearance of
compromising your decisions or judgment in carrying out your University responsibilities?




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Please sign below to certify that (1) you have read the University Conflict of Interest Policy, (2) you have fully and to the best
of your ability completed this Disclosure Survey, and (3) that you will update this Disclosure Survey promptly if relevant
circumstances change.

MEMBER SIGNATURE (full legal name):


                                                                                DATE:

Completed Disclosure Surveys should be returned to Reviewer (see chart below to identify Reviewer).

REVIEWER ACKNOWLEDGEMENT

    I, or my designee, have reviewed this Disclosure Survey and no further action is needed.

    I, or my designee, have reviewed this Disclosure Survey and an actual, potential or perceived Conflict of Interest may
    exist. As such, I, or my designee, will develop a Management Plan, with Member’s input if needed, so that:

    1) Member does not have an opportunity to influence the University’s operational, business, or financial decisions in
       ways that could lead to personal gain or give improper advantage to Member or Member’s family or close relations.
    2) Member can objectively fulfill his or her obligations to the University.

Management Plans must be reviewed by the University Conflicts Committee for final approval before a Member will be
allowed to undertake activities in question. Expedited approval can be requested from the Office of General Counsel.

 Reviewer Name & Title:

 Reviewer Signature:                                                            Date:


Reviewer should keep a copy and then submit ALL signed Disclosure Surveys to Office of General Counsel.

                                                     REVIEWER CHART
                 Member                                       Reviewer                          Management Plan Approval


                  Faculty                        Dean, Designee, or Faculty Conflicts          University Conflicts Committee
                                                            Committee
        Academic Department Chair                Dean, Designee, or Faculty Conflicts          University Conflicts Committee
                                                            Committee
                   Dean                                 Provost or Designee                    University Conflicts Committee

                   Staff                            Department Head or Designee                University Conflicts Committee

 Staff Department Head, Associate Provost,    Supervising Member of the Officers Group         University Conflicts Committee
    Vice President, Assoc. Vice President,                  or Designee
              Athletic Director
      Provost or Exec. Vice President                   President or Designee                  University Conflicts Committee

                 President                                Board of Trustees                      Chair of Board of Trustees

  Students Engaged in Sponsored Research                  Dean or Designee                     University Conflicts Committee



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