Conflict of Interest Disclosure Form
[Company Name] ETHICS COMMITTEE
CONFLICT OF INTEREST DISCLOSURE FORM
Committee Member Information
Full Name:
Position/Title:
Date:
Disclosure Statement
I, the undersigned, acknowledge my understanding of the conflict of interest policy as detailed in the Ethics Committee Charter [add link] I recognize the importance of disclosing any actual, potential, or perceived conflicts of interest that might influence, or appear to influence, my judgment or objectivity in fulfilling my responsibilities to [Company Name].
Definitions Of Interest
Financial Interest: Any economic impact that a Committee member or their immediate family may receive from a decision or action related to their role on the Ethics Committee, including ownership, compensation, intellectual property rights, research funding, or benefiting from financial decisions
Personal Interest: Private, non-financial concerns, relationships, or affiliations that could influence a committee member's judgment or actions in their Committee role, such as close friendships, family relationships, membership in organizations, or positions of authority in other organizations
Professional Interest: Situations where a Committee Member's outside employment, professional affiliations, or career aspirations could influence their decisions or actions in their Committee role. This includes employment or consulting relationships, leadership positions in professional associations, or receiving recognition from institutions affected by the Committee’s actions
If No Conflicts of Interest: If you have none of the above or any other conflicts of interest, check this box and sign below. You do not need to fill out the rest of this form. ● I have no conflict of interest to report
Disclosure
Details of Conflicting Interest
Type of Interest (Please check all that apply):
● Financial Interest
● Personal Interest
● Professional Interest
● Other (Please specify)
Relationship to the Organization/Individual:
(Describe your relationship to the organization or individual that may result in a conflict of interest.)
Duration of Conflict:
(Indicate the period during which the relationship has existed or will exist )
Benefits Received:
(Detail any benefits, financial or otherwise, that you receive from the disclosed interest )
Influence on Decision-Making:
(Describe how the interest could potentially affect or appear to affect your decision-making or actions as a member of the Ethics Committee )
Impact on Confidentiality:
(Could this conflict impact your ability to maintain confidentiality regarding Ethics Committee matters? If so, how?)
Further Description of Interest:
(Provide any further detail necessary to describe the interest that may constitute a conflict )
Management of Conflict
Action Taken to Date:
(Detail any actions you have already taken to manage the conflict of interest )
Proposed Management Strategy:
(Propose strategies for the management of the disclosed conflict of interest )
Signatures on the following page
Declaration
I hereby declare that the information provided herein is accurate and complete to the best of my knowledge I understand that it is my ongoing responsibility to disclose any new conflicts of interest that arise during my tenure as a member of the Ethics Committee
Furthermore, I commit to adhering to any management strategies agreed upon by the Committee or required by [Company Name] policy to address the disclosed conflict of interest.
Consequences for Non-Disclosure: I understand that failing to disclose a known conflict of interest may result in removal from the Committee, corrective action, or other actions as determined by [Company Name] leadership and/or the [Company Name] Board
Confidentiality: Access to this completed form and information contained herein will be restricted to the Ethics Committee Chair and [Company Name] Board
Signatures
Disclosing member:
Committee Member Signature
Printed Name
Date
Committee Chair: Signature required ONLY if disclosure section is filled out, validating receipt of disclosure
Committee Chair Signature
Printed Name
Authorized Signatory for [Company Name]
[Company Name] Signatory
Title or Role
Printed Name Date
Please submit this completed form to the Chair of the Ethics Committee or the designated [Company Name] administrator at [contact information]. If any conflicts arise or circumstances change in the future, it is your duty to update this disclosure accordingly
(For Internal Use Only)
Received By:
Date Received: Action Taken/Follow-up Required: