7.9.16.1 Conflict of Interest Disclosure Form

CLC Potential Conflict of Interest Disclosure

For U.S. Dept. of Labor Grants 

 

Employee Name:  Title: 
Grant:  Supervisor: 

   

Yes     No 

    
  1. Are you or your spouse, partner or dependents (dependent children or other relatives  

living at your same address) an officer, director, partner, trustee, employee, advisory  

board member, or agent of any external organization from which goods or services  

will be obtained under this project? 

 

    
  1. Are you or your spouse, partner or dependents the actual or beneficial owner of more  

than five percent (5%) of the voting stock or controlling interest of any external  

organization from which goods or services will be obtained under this project? 

 

    
  1. Have you or your spouse, partner or dependents received any compensation or anything of monetary value within the past year, or do you or any member of your immediate family, anticipate receiving any compensation or anything of monetary value from any external organization from which goods or services will be obtained under this project?   
   
    
  1. Have you or your spouse, partner or dependents received or expect to receive any  

salary, compensation, consulting fees, honoraria, etc. from any organization other  

than MnSCU for any activity related to your duties as a MnSCU employee? 

   
    
  1. Do you have any other potential conflicts of interest that you are required to  

disclosure or potential conflicts of interest that you would like to make known? 

 

I have read and understand the Central Lakes College Code of Conduct Procedure pertaining to grant proposals;  

have read MnSCU Procedures 1C.0.1 Employee Code of Conduct and 1C.2 Fraudulent or Other Dishonest Acts, and Minnesota Statutes 43A.38 & 43A.39, the U.S Department of Labor Administrative Requirements at 29 CFR Part 95, and other pertinent regulations; have made all required financial disclosures; will comply with any conditions orestrictions imposed by the institution to manage, reduce or eliminate actual or potential conflicts of interest should  

I decide to proceed with the project; and will make Central Lakes College Administration aware in writing of any new conflicts of interest that arise during the period of the award, should the award be received. 

 

 

Signature: ___________________________________________  Date: ____________________ 

 

 

KC:JC – 06/15/2017: CLC #7.9.16.1 

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