Fillable Conflict of Interest Disclosure Details Form Question C (Vanderbilt University)

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Conflict of Interest Disclosure Details Form Question C (Vanderbilt University)

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Conflict of Interest Disclosure Details Form – Question C
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part C. Gifts for Personal Use
1. Please indicate the form of the gift, gratuity or favor received by you or your family member:
2.
Was the gift from a healthcare vendor and/or was the value of the gift greater than or equal to $300?
( ) No ( ) Yes
a. Check all that apply:
Healthcare vendor
Value of gift is greater than or equal to $300.
b. What was the source of the gift? ___________________________________________________________
_____________________________________________________________________________________
c. What was the dollar value of the gift(s) you or your family member received?
_____________________________________________________________________________________
d. What is the donor’s relationship with Vanderbilt?
_____________________________________________________________________________________
e. Have you received approval to accept this gratuity, gift or favor?
( ) No
( ) Yes
Approved by: ___________________________________________
Date: _________________________________________________
f. What safeguards are currently in place or do you propose to prevent this gratuity, gift or favor from affecting
your objectivity as a University employee or that will otherwise protect the University’s interests?
g. Was the VU Development Office notified of this gift?
( ) Yes ( ) No
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Conflict of Interest Disclosure Details Form Question C (Vanderbilt University)

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Completed 24 July 2020

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