East
Carolina University Faculty Manual
APPENDIX
I.
ECU
POLICY ON CONFLICTS OF INTEREST AND COMMITMENT
Example Form A
Year ________
EAST
CAROLINA UNIVERSITY
ANNUAL
FACULTY/PROFESSIONAL STAFF DISCLOSURE FORM
OF
POTENTIAL CONFLICT OF COMMITMENT OR INTEREST ACTIVITIES OR RELATIONSHIPS
Completion of the following questions and associated report forms
are required of all faculty and other EPA employees for compliance with the
University Conflict of Interest & Commitment Policies.
This conflict evaluation form contains information that may have a
direct bearing on your employment, and completing and filing this form is a
condition of your employment. The form, therefore, will be included in your
personnel file. As a part of the personnel file, the form will be considered
strictly confidential. The information disclosed in the form is available only
to individuals duly charged with the responsibility for review, and the
information may be released only in accordance with and as required by North
Carolina law or lawful court order.
Name___________________ Title
& Rank
_______________________________
Dept./Unit__________________ Campus
Address & Tel._______________________
If the answer to any of Questions 1 to 6 is YES then complete the
form: REPORT OF ACTIVITIES AND RELATIONSHIPS WITH ENTERPRISES SPONSORING
UNIVERSITY ACTIVITIES OR DOING BUSINESS WITH THE UNIVERSITY
1. Are you or a member of your immediate family on the Board of
Directors or any Advisory Board of an enterprise that sponsors research,
outreach, extension, testing, or service projects at the University in which
you are a participant or with which the University has a license agreement
relating to an invention or software where you are an inventor or author?
__YES __ NO
2. Are you or a member of your immediate family an employee or
serving in an executive position of an enterprise: a) that sponsors research,
outreach, extension, testing, or service projects in which you are a
participant; b) with which the University has a license agreement relating to
an invention or software where you are an inventor or author; or c) engaged in
commercial activities related to your University responsibilities?
__YES __NO
3. Do you or a member of your immediate family have an
ownership/equity interest/expectancy or other significant financial interest in
an enterprise: a) that sponsors research, outreach, extension, testing or
service projects; b) with which the University has a license agreement relating
to an invention or software where you are an inventor or author; or c) engaged
in commercial activities related to your University responsibilities?
__YES __NO
4. Are you or a member of your immediate family engaged in
external professional activities for pay or an employee of, or otherwise
receiving compensation or gratuities from, an enterprise that sponsors
research, outreach, extension, testing, or service projects in which you are a
participant or with which the University has a license agreement relating to an
invention or software where you are an inventor or author?
__YES __NO
5. Do you supervise, select, or evaluate services provided to the
University by an enterprise or do you refer University business to an enterprise
in which you or a member of your immediate family have an ownership or other
significant financial interest?
__YES __NO
6. Do you participate in
University clinical research on a technology developed by you or a member of
your immediate family?
__YES __NO
If the answer to any one of the Questions 7 ‑ 8 is YES, then
complete the form: REPORT OF POTENTIAL
CONFLICTS OF INTEREST RELATED TO
STUDENTS’ ACTIVITIES WITH EXTERNAL ENTERPRISES
7. Do you supervise any students or University personnel who work
for an enterprise in which you are on the board of directors, an officer, have
ownership interest, or are employed by for external professional activities for
pay?
__YES __NO
8. Do you employ or supervise any
students or University personnel in your external professional activities
for pay or in an enterprise in which you hold ownership/equity
interest/expectancy?
__YES __NO
If the answer to Question 9 or 10 is YES, then complete the form :
REPORT OF CONFLICTS OF INTEREST RELATED TO TEACHING AND OWNERSHIP OF INTELLECTUAL PROPERTY
9. Are you or a member of your immediate family the author of a
textbook. course pack, lab manual or other material for which you or your
immediate family member receives royalties or other compensation from sources
other than the University, that is required for any class that you teach?
__YES __NO
10. Is there any intellectual property (i.e., patent. trademark,
copyright, or trade secret) owned by you which is used or licensed for use by
the University?
__YES __NO
ACKNOWLEDGMENT
I hereby
acknowledge that I have read and understand the Policy on Conflicts of Interest
and Commitment and that the aforementioned facts and situations indicate all
potential conflicts of interest and commitment with regard to my position at
East Carolina University according to the standards and guidelines of the
Policy. If I have none, I have so
indicated in the spaces provided.
I acknowledge that
I have a continuing obligation to file an updated form prior to filing the next
annual report if changes arise that I believe either: (a) give rise to a potential conflict of interest, or (b)
eliminate a conflict previously described.
Signed this day
of _______, 20__ _____________________Signature
ADMINISTRATIVE REVIEW AND APPROVAL
To the best of
my knowledge and judgment and according to the standards and guidelines of the
Policy:
___No actual or
potential conflict of interest or commitment exists.
___ An actual or potential conflict of interest or commitment may exist, but does not appear to be significant. (Attach explanation.)
___An actual or potential conflict of interest or
commitment may exist that warrants further review.
______________________________________
Dept.
Chair/Supervisor Date
________________________________________
Dean/Senior
Supervisor Date (If Approval Is Required According to the
Policy)
_______________________________________
Vice Chancellor Date (If applicable)