Faculty Conflict Disclosure Form
Please disclose any actual, potential, or perceived conflicts of interest or commitment related to your university duties. Complete all sections accurately.
Faculty Member Full Name
*
First Name
Last Name
Department
*
Type of Conflict
*
Please Select
Actual Conflict
Potential Conflict
Perceived Conflict
Brief Description of the Conflict
*
Parties or Entities Involved
*
Dates or Time Period Affected
*
University Duties Affected
*
Teaching
Research
Procurement
Supervision
Outside Employment
Consulting
Other
Steps Already Taken to Mitigate the Conflict
Declaration: I confirm that the information provided above is accurate and complete to the best of my knowledge.
*
I Agree
Submit Disclosure
Should be Empty: