Conflict of Interest Disclosure Details Form – Question C
Name: ________________________________________ Job Title: _________________________
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:
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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