Conflict of Interest Form
TO BE COMPLETED WHEN YOU HAVE A CONFLICT TO DISCLOSE OR A CHANGE
IN CONFLICT CIRCUMSTANCES
EMPLOYEE INFORMATION:
Name Bengal ID No.
Campus Phone No. Department
Position Title Email Address
I have a new conflict to report.
This report is made following a change of circumstances and replaces my prior report.
Employee Conflicts of Interest Disclosure
By signing here, you are certifying that the information that you provide in this form and in the management
plan (if necessary) is accurate to the best of your knowledge as of the date of your signature, and you commit to
providing an updated form to your supervisor if a material change occurs in the information you have
provided. Please sign and date this form and submit it to your department head or chair supervisor/institute
director along with separate pages describing the nature of the reported conflict.
Signed Date
Supervisor Review
I concur with the employee’s conflict(s) and the plan(s) to manage the conflict(s).
I do not concur with the employee’s management of one or more conflicts. Attached are my
reasons for not concurring.
Date
Department Head or Chair /Supervisor/ Director
Unit Administrator Review
I concur with the supervisor’s review.
I do not concur with the supervisor’s review. Attached are my reasons for not concurring.
Date
Dean/ Unit Administrator
Committee on Ethical Guidance and Oversight Action
I concur with the above reviews and the proposed management plan.
I do not concur with the above reviews and the proposed management plan. Attached are the
required actions.
Date
Chair, Ethical Guidance and Oversight Committee
Copy to employee, employee’s supervisor, and employee’s unit administrator
Original document on file in the office of Human Resources
