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Policy #54
Appendix A

Conflict-of Interest Disclosure Form
In completing this form about my activities for the 20_____ - 20_____ academic year, I affirm that I have read and understand the policies of Western Carolina University regarding conflict-of-interest. To the best of my knowledge, the information provided by me is true. 


Employee Name (print)________________________________________________

Signature of Employee _______________________________________Date_____________

Unit (department) ____________________________________________________________

 

 

____ I have professional activity external to Western Carolina University which is described in the "Notice of Intent to Engage in External Professional Activities for Pay" form.

____ I have no conflict-of-interest activities to report. [If you check this item, this form may now be submitted to your unit head.]

____ I am engaged in the following activities or interests that may present conflict-of-interest:

 
Describe your activities. For whom are the activities performed? What WCU responsibilities, if any, will be missed? How will these be fulfilled?

 

 

 

    
Do you have a consulting or other financial relationship with a sponsor of your professional activities? [If YES, please explain in an attachment statement.]
Yes
No
Do you or any member of your immediate family have any other relationships, commitments, or activities that might present or appear to present a conflict-of-interest with your appointment at Western Carolina University? [If YES, please explain in an attachment statement.]
Yes
No

Review of Unit Head or Other Administrative Officials:
After reviewing the information provided above and the attachments, is there a violation of the conflict-of-interest policy of Western Carolina University?
Level I (unit head)
Yes
No
Level 2 (unit head's supervisor) (if necessary)
Yes
No

Level 3 (Vice Chancellor) (if necessary)

Yes
No
Signature of unit head (Level 1) Date
Signature of unit head's supervisor (Level 2) Date
Signature of appropriate Vice Chancellor (Level 3) Date
The reviewing official will retain one copy of the form. A second copy is to be provided to the person filing this form. The original copy is to be provided to the custodian of the employee's official personnel file for retention. 11/93