Conflict of Interest Disclosure Details Form – Question B
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part B. Family Members Working Together at Vanderbilt
If you are disclosing a potential conflict with more than one family member, you will need to add additional disclosure detail
sheets.
Name of your family member employed at Vanderbilt:
Relationship to you: _____________________________________________________
Their Position: _________________________________________________________
Their Department: ______________________________________________________
Their Supervisor: _______________________________________________________
1. Working relationship (a working relationship means that you have business-related contact). Please check all that apply.
I work in the same department as this family member.
I was involved in the hiring process for this family member.
I directly or indirectly supervise this family member.
I am directly or indirectly responsible for this family member’s performance review.
I directly or indirectly determine compensation for this family member
I directly or indirectly assign work to this family member who also works at Vanderbilt
Other (explain):__________________________________________________________________________
______________________________________________________________________________________
2. Have you reported this business/activity in prior years?
( ) Yes ( ) No
2a. Have you received approval for your involvement?
( ) Yes ( ) No
Approved by: ______________________________
Date: ___________________________________
3. What safeguards are currently in place or do you propose to assure objectivity in this relationship?
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