Support Staff Disclosure Report
Support staff with financial duties (e.g. purchasing), hiring, and/or research
responsibilities are required to annually complete a Disclosure Report,
answering all of the questions below.
Staff and/or supervisors requiring assistance
with completing this form, please contact HR
Partnerships at hrpartnerships@ualberta.ca or
call (780) 492- 6860
Please fill out form, print, sign and then submit to your supervisor.
About Conflicts of Interest
Support Staff at the University of Alberta may sometimes do things or have relationships that may be seen to be a real or perceived conflict of interest or
conflict of commitment.
The University’s policy on Conflict of Interest and Commitment and Institutional Conflict requires that staff with certain responsibilities, or staff who self-identify
that they may be in a position of conflict, complete a Conflict of Interest and Conflict of Commitment Disclosure Report annually.
Not all conflicts will impact upon an employee’s job or work assignment. However, to ensure that the interests of the individual employee and the University
are protected, conflicts must be reported so that the University can assess the impact of such conflicts. The University needs to be able to demonstrate during
reasonable and independent scrutiny that it has a process to identify and resolve conflicts that may exist.
You may have been identified by your manager as someone who needs to complete the report because of the nature of your work, or you may feel that you
may be in a position of conflict for some reason. In either case, you should complete the Disclosure Report.
Question 1
A. Does your work for the University put you in a conflict of interest due to your dealings with your family?
Choose an item.
B.
Does your work for the University put you in a conflict of interest due to your dealings with other people?
Choose an item.
C.
Does your work for the University put you in a conflict of interest due to your dealings with other businesses or companies you are a part of?
Choose an item.
D.
Does your work for the University put you in a conflict of interest due to your dealings with any other organizations you support or work with?
Choose an item.
If you answered yes to any part of this question, please explain. Include the pros and the cons for the University of your current relationships:
Enter text here
Question 2
A. Do you have any influence or control over the use of any University funds?
Choose an item.
If yes:
B. Will you receive or do you expect to receive a financial benefit from any payments out of the University money you have influence or control over?
Choose an item.
C.
Will a member of your family receive or expect to receive a financial benefit from any payments out of the University money you have influence or
control over?
Choose an item.
D.
Will a company or business you own or are involved in receive or expect to receive a financial benefit from any payments out of the University
money you have influence or control over?
Choose an item.
If you answered yes to any part of this question, please explain. Include any reasons you believe the University may benefit from this type of
payment to you, your family, or your business or company.
Enter text here
Question 3
A. Will you receive or do you expect to receive a financial benefit from the University of Alberta in the form of a fee-for-service or other payment? (This
does not include your salary or other benefits available under any collective agreements)
Choose an item.
B.
Will a member of your family receive or expect to receive a financial benefit from the University of Alberta in the form of a fee-for-service or other
payment?
Choose an item.
C.
Will a company or business you own or are involved in receive or expect to receive a financial benefit from the University of Alberta in the form
of a fee-for-service or other payment?
Choose an item.
If you answered yes to any part of this question, please explain what service you or your business provides or is expecting to provide to the
University, and how the service may benefit the University:
Enter text here
HR Partnerships, Human Resource Services
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January 2015
Support Staff Disclosure Report
Question 4
A. To the best of your knowledge, does any member of your family have or expect to have a financial or non-financial relationship with the University of
Alberta that might cause a potential conflict of interest for you?
Choose an item.
If you answered yes, please explain:
Enter text here.
Question 5
With respect to the people, businesses or other organizations you interact with during your work for the University of Alberta:
A. Do you personally receive or expect to receive a financial benefit from them?
Choose an item.
B.
Does a member of your family receive or expect to receive a financial benefit from them?
Choose an item.
C.
Does a company or business you own or are involved in receive or expect to receive a financial benefit from them?
Choose an item.
If you answered yes to any part of this question, please explain:
Enter text here
Question 6
A. Are you involved in any other outside activities that are not part of your job at the University that might put you in a conflict of commitment?
Choose an item.
If you answered yes, please explain. Include the pros and the cons for the University because of your involvement in these activities:
Enter text here
NOTE: Questions #7 & #8 exclude reasonable official work undertaken on behalf of NASA.
Question 7
A. Will you make significant use (meaning beyond that of a purely incidental nature with or without an attributed or allocated cost) of University space,
facilities, general supplies and/or equipment, including communication devices, and confidential information to support any activities that do not
directly pertain to your employment obligations to the University?
Choose an item.
If yes, please explain the nature of this use. Describe the benefits that the University will derive from your use of the facilities or property:
Enter text here.
Question 8
A. Are you aware of any other potential conflicts of interest or conflicts of commitment, real or perceived, that will affect you as an employee of the
University?
Choose an item.
If yes, please explain the nature and details of the potential conflict of interest and/or commitment. Describe the benefits that the University will derive
from these activities:
Enter text here.
Declaration of Support Staff
I hereby verify that the information contained in this annual disclosure report is true and correct to the best of my knowledge.
I agree to submit another report as soon as my circumstances change. I understand that if I am unsure about whether or not I should do another report, I
should speak to my supervisor to help me decide.
I understand that if I need the assistance of my NASA representative at any time to complete this or future disclosure reports or to help me decide if a new
report is needed, I am entitled to the help of my NASA representative.
I understand that this report will be used by the University as required but the information will be shared only with those people who are required to know it.
___________________________________________________
Employee Name (PRINTED)
_________________________________________________
Employee Signature
HR Partnerships, Human Resource Services
_________________________________________________
DATE
January 2015
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