Conflict of Interest Disclosure Details Form – Question D
Name: ________________________________________ Job Title: _________________________
(PLEASE PRINT CLEARLY)
Department: ____________________________________________________________________
Part D. Outside Jobs/Activities or Other Relationships
1. Describe your outside job, activity(ies) or relationship(s):
2.
Have you used Vanderbilt’s name, resources (facilities, personnel, or equipment), or confidential information in
connection with the outside activities?
( ) Yes ( ) No
If YES, please describe and explain:
3. Have you reported this business/activity in prior years?
( ) Yes ( ) No
3a. Have you received approval for your involvement?
( ) Yes ( ) No
Approved by: _________________________________________________
Date: _______________________________________________________
4. What safeguards are currently in place or do you propose to prevent this activity from creating a conflict of
interest?
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