Non-Research COI/COC & Potential Nepotism Disclosure Form

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NON-RESEARCH CONFLICTS OF INTEREST & COMMITMENT AND POTENTIAL NEPOTISM

Contact Information

ContactID

College or Unit

Supervisor Method

This Disclosure Form should be completed following review of University Policy 4.14 Non-Research Conflicts of Interest and Commitment and University Policy 6.14 Avoiding Nepotism. Answering affirmatively to any question does not necessarily mean that the situation is improper, but that disclosure, evaluation, approval, management, and/or oversight may be required. These disclosure statements will remain confidential and will only be reviewed by your local HR representative and college or unit leadership. If you have any questions, please contact your supervisor or unit head.

Gifts and Gratuities

1. Did you or a family member receive or may receive (in your capacity as a Cornell employee) any gifts, favors, or other perks with a value of more than $75 from any non-Cornell individual or entity?

YesNo

If yes, list the source and type (such as non-business meals or entertainment, subsidized travel, event tickets, merchandise, etc.):

Your supervisor or unit head will consult with you as to whether acceptance of the item interferes in any way with the impartial discharge of duties.

Management or Fiduciary Activities to an Outside Organization

2. Do you have, or will you have, any managerial responsibilities (including self-employment) for any company or organization outside of Cornell?

YesNo

If yes, please describe:

Use of University Resources

3. Do you use or anticipate using Cornell facilities or equipment owned or operated by Cornell to support an external entity or activity (including consulting)?

YesNo

If yes, please describe:

4. Do you use or anticipate using Cornell students or staff over whom you exercise supervisory or academic responsibility to support an external entity or activity (including consulting)?

YesNo

If yes, please describe:

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Outside Employment, Civic Activities, and other External Commitments or Potential Conflicts

10. Have you received more than $5,000 income from any single non-Cornell source during the calendar year or expect to do so in the next 12 months? (Includes salary, consulting fees, paid speaking engagements, expert witness testimony fees, honoraria, expense reimbursement, etc.)

YesNo

If yes, please list the source, amount, and the type of income:

11. Do you hold or plan to seek election or appointment to a public office during the next 12 months?

YesNo

If yes, please describe:

12. Are there any other situations that you may reasonably foresee as creating an actual or potential conflict of interest or commitment between your role at Cornell and an outside interest, activity, or relationship (including an actual or perceived ability to influence or derive personal benefit)?

YesNo

If yes, please describe:

I acknowledge that I have read and understand University Policy 4.14 Non-Research Conflicts of Interest and Commitment and University Policy 6.14, Avoiding Nepotism and I certify that I have provided complete and accurate answers to the questions above.

I Acknowledge

Acknowledgement Date (mm/dd/yy):

Full Name

NetID

Please enter the NetId of the individual who has been designated to receive conflict of interest disclosures on behalf of your unit (designated recipient). If not known, contact your supervisor for this information.

Note: This form contains confidential information. Please verify that you have entered the correct NetIds before clicking 'Submit' to prevent disclosure to unintended recipients.

Designated Recipient NetId:

Name:

Key Fields

Month

Year

Day

Hour

Minute

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Key

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