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 INTERESTRELATED TO STUDENTSí 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 ANDOWNERSHIP 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

 

 

ADMINISTRATIVEREVIEW 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.)

 

___Anactual 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)