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