Conflict of Interest and
Conflict of Commitment1
DISCLOSURE REPORT FOR MEMBERS OF THE BOARD OF GOVERNORS
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
Members of the Board of Governors of the University of Alberta (hereafter referred to as Board Members) may on
occasion be involved in activities that could be construed to constitute a real or perceived conflict of interest or conflict of
commitment (see definitions below).
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 Commitment Disclosure Report (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 & Conflict of Commitment Disclosure Form
This Form comprises 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 report.
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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.
Person’s Family
Includes a Person’s spouse or adult interdependent partner, dependent children and any
other family members or individuals who are adult independent partners of individuals
living in the Person’s household.
CONFLICT OF INTEREST AND CONFLICT OF COMMITMENT
DISCLOSURE REPORT FOR MEMBERS OF THE BOARD OF GOVERNORS (TO BE COMPLETED IN FULL)
BOARD MEMBER (Name)
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.
For external members of the Board of Governors Committees, the Chair of the Board of Governors is the Reporting Officer.
POSITION
DISCLOSURE REPORT FOR MEMBERS OF THE BOARD OF GOVERNORS
PART A
1. Have there been any changes in the facts disclosed in your last report? Yes
No

If you answered “Yes” or if this is your first report, complete the information above and the questions on the
following pages (PART B), and submit your signed form 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 Chair 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 this information is collected under the authority of section 33 (c) of the Freedom of Information and
Protection of Privacy Act RSA 2000, c. F-25. 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 BOARD MEMBER
DATE (Month, Day, Year)
I hereby signify that I have reviewed this report, assessed any reported conflict, and handled as appropriate.
Signature of Chair of the Board of Governors
DATE (Month, Day, Year)
2
DISCLOSURE REPORT FOR MEMBERS OF THE BOARD OF GOVERNORS
PART B
1. CONFLICT OF INTEREST – NON-FINANCIAL
A
WILL YOUR ACTIVITIES AS A BOARD MEMBER OF THE UNIVERSITY OF ALBERTA 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
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
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
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 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
2
Corporation would include a spin-off company or other corporation with which the Reporting Individual is associated.
3
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
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.
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DISCLOSURE REPORT FOR MEMBERS OF THE BOARD OF GOVERNORS
3. OTHER CONFLICT
A
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 BOARD OF GOVERNORS 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
4. REPORTING INDIVIDUAL’S CERTIFICATION
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 BOARD MEMBER
DATE (Month, Day, Year)
I hereby signify that I have reviewed this report, assessed any reported conflict, and handled as appropriate.
Signature of the Chair of the Board of
Governors
DATE (Month, Day, Year)
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