CONFLICT OF INTEREST DECLARATION

Instructions

Complete this form if there is any real or potential conflict of interest (person with conflict)
Complete this form if you work for another organisation
Management to determine and record how to manage any conflict
Details must be recorded in the Conflict of Interest Register

Employees Name

Employees Position

Has the conflict occurred?

YesNo

If yes, date occurred:

If no, when is it possible or likely to occur?

List potential, perceived or real conflict of interest

Identify what conflict of interest involves

1. Employer Name

1. Type of Work

2. Employer Name

2. Type of Work

3. Employer Name

3. Type of Work

Describe how the matter was dealt with

List any follow-up actions required

Name Declaration made by:

Date

Signature

Draw signature|Type signatureClear

Management Committee notified on date

Date Entered on Register

Save and Complete Later