East
Carolina University Faculty Manual
APPENDIX
I.
ECU
POLICY ON CONFLICTS OF INTEREST AND COMMITMENT
Example
Form C
REPORT OF POTENTIAL CONFLICTS OF INTEREST RELATED TO
STUDENTS' ACTIVITIES WITH EXTERNAL ENTERPRISES
Faculty responding affirmatively to one or
more of Questions 7-8 on the Annual Faculty Report of Potential Conflict of
Interest Activities or Relationships form must complete the disclosure process
by providing the information requested below.
If additional space is needed attach separate sheets labeled
"REPORT OF POTENTIAL CONFLICTS OF INTEREST RELATED TO STUDENTS' ACTIVITIES
WITH EXTERNAL ENTERPRISES Continued" and note the answer number for which
additional information is provided. A
separate form should be used to report relationships with each enterprise or
corporation.
___________________ _______________________
______________________
______________
Employee Name Department College/School Reporting Period
_________________________________________________________________________________
If reporting for an immediate family member,
give his or her name and relationship.
_____________________________ __________________________________________________
Enterprise/Corporation Name Complete Address
_________________________________________________________________________________
Principal Business of Enterprise/Corporation
Complete ITEMS 1-3 if you answered YES to
Question 7 on the Annual Faculty Report Form.
1.
Describe the number and levels of the students involved, your relationship with
the enterprise, and how this relationship involved the students.
2. Describe the nature of the relationship of
this enterprise with the University.
3.
Discuss the actions or safeguards you will take to prevent your relationship
with this enterprise from affecting your responsibilities as a University
employee for supervising these students.
Complete ITEMS 4-5 if you answered YES to
Question 8 on the Annual Faculty Report Form.
4. Describe the numbers of students, their status and the nature and scope of the duties for which they are employed.
5.
Discuss the actions or safeguards you will take to prevent your relationship
with this enterprise from affecting your responsibilities as a University
employee for supervising these students.
SIGNATURES:
I certify that all of the above information
is correct and that I will update this information promptly as changes occur.
____________________________________________
Employee Signature Date
Reviewed by: Approved by:
_____________________________________
_____________________________________
Department Head Date Dean Date