CERTIFICATE
OF COMPLIANCE WITH CONFLICT OF INTEREST POLICY
To the Employees of
Disclosure: Most issues with
conflicts of interest can be prevented through prompt and thorough disclosure
of the activity. It is the
responsibility of all employees to disclose anything that is, or may appear to
be, a conflict of interest. Your
supervisor must approve all such disclosures and retain a copy of the Certificate of Compliance form. Forward the original Certificate of Compliance
to Accounts Payable.
If a potential conflict is disclosed, the employee(s) involved shall refrain from participation in the identified activity until the matter has been resolved.
Name:
Position:
1. Have you read and do you understand the attached “Conflict of Interest Policy for DePaul University Employees”?
YES NO
2. Do you certify that you are in compliance with the requirements in the Conflict of Interest Policy?
YES NO
3. Are you aware of any relationships involving you or a related individual and might give rise to an actual or appearance of a conflict of interest under the Conflict of Interest Policy?
YES NO
4. If the answer to #3 above is yes, please supply (either in the space provided below or on a separate sheet) a description of the pertinent facts giving rise to the actual or appearance of a conflict. (Include name of conflicting entity or activity, relationship, value or dollars involved, and safeguards to prevent abuse (such as competitive bids or involvement of other University Employees without conflicts)).
I have read and understand both the Conflict of Interest Policy for DePaul University Employees and this Certificate of Compliance. I understand that I am obligated to immediately update this compliance statement should I, at any time in the future, become involved in an activity and/or relationship which could be construed as a conflict of interest as defined by the Conflict of Interest Policy for DePaul University Employees. I certify that the foregoing information is true and complete to the best of my knowledge and understand that any false statements on this form and/or the withholding of information will be sufficient grounds for disciplinary action, up to and including dismissal, and/or personal liability for any losses or damages sustained by the University as a result of my actions.
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Employee Signature Date |
Supervisor’s Approval Date |
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CONFLICT OF INTEREST POLICY FOR