East Carolina University Faculty Manual
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.
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