Conflict of Interest and
Conflict of Commitment1
DISCLOSURE REPORT FOR ACADEMIC STAFF
FORM INSTRUCTIONS
This is an electronic form. All applicable fields must be typed. To advance to the next field, press the “Tab” key. To go
back to the previous field, press the keys “Shift” and “Tab” simultaneously.
Preamble
Conflicts may be viewed and reported in three contexts:
1.
The very nature of research activities may give rise to the potential for Conflict of Interest in research.
2.
The University’s ever-increasing interaction with the community at large brings with it a greater likelihood that
perceived or real Conflicts of Interest of other types (non-research) could arise.
3.
The many and varied activities engaged in by members of the University have the potential to give rise to Conflicts
of Commitment.
For any such conflicts to be allowed, related considerations must be reported, assessed and managed in a way that would
withstand reasonable and independent scrutiny, and in a way that is legislation-compliant, and that considers, protects
and serves the interests and reputation of the University.
This Conflict of Interest and Conflict of Commitment Disclosure Report (Disclosure Report) is intended to gather the
relevant information for conflict considerations. Some responses may include personal information as defined by the
Freedom of Information and Protection of Privacy Act, RSA 2000 F-25. The Act, (Section 33(c)) provides the legislative
authority to collect this information.
Completing this Conflict of Interest and Conflict of Commitment Disclosure Report
1.
All staff appointed under the following agreements must complete this Disclosure Report:
a.
b.
c.
d.
Faculty Agreement;
Librarian Agreement;
Faculty Service Officer Agreement;
Administrative and Professional Officer Agreement.
2.
This Disclosure Report is comprised of two parts: PART A should be completed and submitted by reporting
individuals whose circumstances remain unchanged from the previous reporting year. PART B should be completed
and submitted by reporting individuals whose circumstances have changed or who have not previously completed a
Disclosure Report.
3.
All Supplemental Professional Activity (under the respective staff agreement) must be disclosed in this Disclosure
Report. Reporting individuals should indicate this designation in their explanation of the conflict (see Part B of this
Disclosure Report).
4.
Reporting Officers are not required to sign the Disclosure Reports they receive from Reporting Individuals; however,
they retain responsibility for the assessment of reported conflict (refer to Conflict of Interest and Conflict of
Commitment Reporting & Assessment Procedure).
5.
In all instances of conflict involving research, the Disclosure Report should be submitted to the individual’s Reporting
Officer who will then consult with the Dean, Vice-President (Research), and Faculty Relations, as appropriate.
1
Definitions from University of Alberta Conflict Policy:
(https://www.conman.ualberta.ca/stellent/groups/public/@academic/documents/policy/pp_cmp_051034.hcsp)
Conflict of Commitment
A situation whereby the external or personal activities, undertakings or relationships of a
Person are so demanding or organized in such a manner or are otherwise such that they
may interfere with the person’s obligations to the University or to others or institutions
that are separate from the University but to whom the Person owes an obligation
because of their relationship to the University.
Conflict of Interest
A situation in which there is or may be perceived to be a divergence between the private
financial benefit or financial interest or personal benefit of a person, family member, or
an outside party, and that person’s obligations to the University, such that an impartial
observer might reasonably question whether related actions to be taken or decisions
made by the person would be influenced by consideration of the person’s own interests.
DISCLOSURE REPORT FOR ACADEMIC STAFF
REPORTING INDIVIDUAL’S INFORMATION (TO BE COMPLETED IN FULL)
REPORTING INDIVIDUAL
POSITION
DEPARTMENT & FACULTY
DISCLOSURE PERIOD
July 1,
to June 30,
REPORTING OFFICER (must be completed)
Note: The Reporting Officer is as defined in the Conflict of Interest and Conflict of Commitment Reporting & Assessment
Procedure (https://www.conman.ualberta.ca/stellent/groups/public/@academic/documents/procedure/pp_cmp_051035.hcsp ).
Example: For academic staff of a faculty with departments, the Chair is the Reporting Officer.
POSITION
PART A
1. Have there been any changes in the facts disclosed in your last Disclosure Report? Yes
No

If you answered “Yes” or if this is your first Disclosure Report, complete the information above and the questions
on the following pages (PART B), and submit your signed Disclosure Report to your Reporting Officer.

If you answered “No,” complete the information above, the following declaration, and submit only this page (2) to
your Reporting Officer.
REPORTING INDIVIDUAL’S DECLARATION
I declare that the information contained in this Disclosure Report is true and correct to the best of my knowledge,
information, and belief.
I will promptly submit a revised report if at any time during the disclosure period circumstances warrant a different
response to any of the questions in this Disclosure Report.
I have read the University of Alberta’s Conflict Policy and understand this Disclosure Report is given in accordance with
that Policy. I understand that if I have indicated that I may become involved in activities which could give rise to a conflict
of interest or a conflict of commitment, I shall not engage in these activities until such time as the conflict considerations
are assessed and resolved. If I have indicated that I am presently involved in activities which could give rise to a conflict of
interest or a conflict of commitment, I understand that I may continue the activity until such time as the conflict
considerations are assessed and resolved, unless I am ordered by the Conflict Review Officer (in consultation with the
appropriate Vice-President) to cease the activity. I understand that the order to cease the activity shall stand until such
time as the conflict considerations are assessed and resolved.
I understand that the personal information requested on this form is collected under the authority of section 33 (c) of the
Alberta Freedom of Information and Protection of Privacy Act for the purposes of determining possible conflict of interest. I
hereby consent to the use of the information provided by the University for the purpose of assessing conflict.
I understand that I will be consulted if certain public disclosure of information is deemed appropriate in managing an
assessed conflict. I understand that consent for any such public disclosure will be addressed at that time.
Signature of REPORTING INDIVIDUAL
DATE (Month, Day, Year)
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DISCLOSURE REPORT FOR ACADEMIC STAFF
PART B
1. CONFLICT OF INTEREST – NON-FINANCIAL
A
WILL YOUR UNIVERSITY TEACHING, RESEARCH, OR ADMINISTRATIVE ACTIVITIES INVOLVE YOU IN DEALINGS WITH
INDIVIDUALS, BUSINESSES, OR CORPORATIONS2 IN WAYS THAT MIGHT BE VIEWED BY A REASONABLE OBSERVER AS A
CONFLICT OF INTEREST?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE NAMES OF THE INDIVIDUALS, BUSINESSES OR CORPORATIONS, THE NATURE OF YOUR INVOLVEMENT, AND
RELATED PARTICULARS
DESCRIBE THE BENEFITS THAT THE UNIVERSITY WILL DERIVE FROM THESE ACTIVITIES
B
ACADEMIC STAFF FREQUENTLY PARTICIPATE IN ACTIVITIES OF SERVICE (VOLUNTARY) TO THE COMMUNITY AND
SOCIETY AT LARGE. WILL YOU BE INVOLVED IN SERVICE ACTIVITIES, OUTSIDE THE UNIVERSITY OF ALBERTA, THAT
MAY GIVE RISE TO CONFLICTS OF INTEREST?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE NAME OF THE OUTSIDE PARTIES WITH WHOM YOU ARE INVOLVED AND THE NATURE OF YOUR
INVOLVEMENT (e.g., A BOARD MEMBER, ADVISOR, DIRECTOR)
DESCRIBE THE BENEFITS THAT THE UNIVERSITY WILL DERIVE FROM THESE ACTIVITIES OF SERVICE
2. CONFLICT OF INTEREST – FINANCIAL
A
WILL YOU OR A MEMBER OF YOUR FAMILY3 OR YOUR CORPORATION BE THE RECIPIENT(S) OF FINANCIAL INTEREST OR
FINANCIAL BENEFIT FROM UNIVERSITY FUNDS OVER WHICH YOU EXERCISE INFLUENCE?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE PARTICULARS OF THE FINANCIAL INTEREST OR BENEFIT
B
WILL YOU OR YOUR CORPORATION HAVE, OR ANTICIPATE HAVING, A FINANCIAL BENEFIT FROM THE UNIVERSITY OF
ALBERTA IN THE FORM OF FEE-FOR-SERVICES OR OTHER REMUNERATION?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE PARTICULARS OF THE FEE-FOR-SERVICES OR OTHER REMUNERATION THAT YOU OR YOUR CORPORATION
ANTICIPATES RECEIVING NOT INCLUDING YOUR NORMAL SALARY
C
TO THE BEST OF YOUR KNOWLEDGE, DOES OR WILL A MEMBER OF YOUR FAMILY HAVE A RELATIONSHIP (FINANCIAL or
NON-FINANCIAL) WITH THE UNIVERSITY THAT MIGHT BE VIEWED BY A REASONABLE INDIVIDUAL TO CONSTITUTE A
POTENTIAL CONFLICT OF INTEREST FOR YOU?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE PARTICULARS OF YOUR FAMILY MEMBER’S RELATIONSHIP WITH THE UNIVERSITY
2
Corporation would include a spin-off company or other corporation with which the Reporting Individual is associated.
Concerning a family member’s involvement, the Freedom of Information and Protection of Privacy Act, RSA 2000 F-25, is restrictive in the
authority for indirect collection of personal information. Therefore, in a case where an informed assessment of conflict requires specific
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DISCLOSURE REPORT FOR ACADEMIC STAFF
details of a family member’s interest from the family member, information concerning financial interest or benefit will be collected from the
family member. If the Reporting Officer is unable to obtain this information, a conflict shall be deemed to exist.
D
WILL YOU, YOUR FAMILY, OR YOUR CORPORATION HAVE, OR ANTICIPATE HAVING A FINANCIAL INTEREST IN, OR
RECEIVE A FINANCIAL BENEFIT FROM, ANY OUTSIDE PARTY WHOSE ACTIVITIES ARE CONNECTED TO YOUR RESEARCH
OBLIGATIONS TO THE UNIVERSITY?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE PARTICULARS OF THE FINANCIAL INTEREST OR FINANCIAL BENEFIT
3. CONFLICT OF COMMITMENT
A
ACADEMIC STAFF FREQUENTLY PARTICIPATE IN ACTIVITIES THAT ARE NOT INCLUDED IN THEIR TERMS OF
EMPLOYMENT WITH THE UNIVERSITY OF ALBERTA. POTENTIALLY, WILL YOUR COMMITMENT TO THESE ACTIVITIES
PLACE YOU IN A CONFLICT OF COMMITMENT TO THE UNIVERSITY OF ALBERTA?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE NATURE OF THE COMMITMENT AND YOUR TIME OF INVOLVEMENT IN THAT OUTSIDE ACTIVITY
HOW WILL THIS COMMITMENT AFFECT YOUR EMPLOYMENT OBLIGATIONS TO THE UNIVERSITY OF ALBERTA?
DESCRIBE THE BENEFITS THAT THE UNIVERSITY WILL DERIVE FROM YOUR COMMITMENT TO THIS UNDERTAKING
4. OTHER CONFLICT
A
DO YOU INTEND TO USE THE SERVICES OF UNIVERSITY STUDENTS, UNIVERSITY EMPLOYEES, OR OTHERS UNDER
CONTRACT TO THE UNIVERSITY OVER WHOM YOU EXERCISE SUPERVISORY OR ACADEMIC RESPONSIBILITY, FOR A
PURPOSE BEYOND THOSE DIRECTLY ASSOCIATED WITH YOUR EMPLOYMENT OBLIGATIONS TO THE UNIVERSITY?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
IDENTIFY THE NATURE AND DURATION OF THE SERVICES
B
WILL YOU MAKE SIGNIFICANT USE (MEANING A USE 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?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE NATURE OF THESE USES
DESCRIBE THE BENEFITS THAT THE UNIVERSITY WILL DERIVE FROM YOUR USE OF THE FACILITIES OR PROPERTY
C
ARE YOU AWARE OF ANY OTHER POTENTIAL CONFLICTS OF INTEREST OR CONFLICT OF COMMITMENT, REAL OR
PERCEIVED, THAT WILL AFFECT YOU AS A MEMBER OF THE UNIVERSITY’S ACADEMIC STAFF DURING THE UPCOMING
REPORTING PERIOD?
Yes
No
IF YOU ANSWERED “YES,” PLEASE PROVIDE THE FOLLOWING INFORMATION:
STATE THE NATURE AND DETAILS OF THE POTENTIAL CONFLICT OF INTEREST AND/OR COMMITMENT
DESCRIBE THE BENEFITS THAT THE UNIVERSITY WILL DERIVE FROM THESE ACTIVITIES
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DISCLOSURE REPORT FOR ACADEMIC STAFF
5. REPORTING INDIVIDUAL’S DECLARATION
I declare that the information contained in this Disclosure Report is true and correct to the best of my knowledge,
information, and belief.
I will promptly submit a revised report if at any time during the disclosure period circumstances warrant a different
response to any of the questions in this Disclosure Report.
I have read the University of Alberta’s Conflict Policy and understand this Disclosure Report is given in accordance with
that Policy. I understand that if I have indicated that I may become involved in activities which could give rise to a conflict
of interest or a conflict of commitment, I shall not engage in these activities until such time as the conflict considerations
are assessed and resolved. If I have indicated that I am presently involved in activities which could give rise to a conflict of
interest or a conflict of commitment, I understand that I may continue the activity until such time as the conflict
considerations are assessed and resolved, unless I am ordered by the Conflict Review Officer (in consultation with the
appropriate Vice-President) to cease the activity. I understand that the order to cease the activity shall stand until such
time as the conflict considerations are assessed and resolved.
I understand that the personal information requested on this form is collected under the authority of Section 33 (c) of the
Alberta Freedom of Information and Protection of Privacy Act for the purposes of determining possible conflict of interest. I
hereby consent to the use of the information provided by the University for the purpose of assessing conflict.
I understand that I will be consulted if certain public disclosure of information is deemed appropriate in managing an
assessed conflict. I understand that consent for any such public disclosure will be addressed at that time.
Signature of REPORTING INDIVIDUAL
DATE (Month, Day, Year)
COMPLETION INSTRUCTIONS
Please ensure you have completely filled out every applicable field in this Report. When you are ready to submit your
Report, please follow these instructions:
1. Print the Report.
2. Sign the Report.
3. Send and/or deliver the Report to your Reporting Officer.
Form updated on May 21, 2010
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