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Office of Justice ProgramsU.S. Department of Justice

DISCLOSURE OF CONFLICT OF INTEREST

As a peer reviewer for the Office for Victims of Crime (OVC), I believe that I have thefollowing potential conflict of interest with a proposal that I have been assigned to reviewunder this solicitation, Public Awareness and Outreach for Victims in UnderservedCommunities & OVC-2010-2635.

1. _____I am listed as a staff member, consultant, or advisor on a proposal under this solicitation.

2. _____My spouse, child or other family member is an employee or consultant to an applicant, or isseeking employment with an applicant under this solicitation.

3. _____My spouse, child, other family member, or business partner would be employed under aproposal or a subpart.

4. _____I have, or have had, a close personal relationship with the author(s)/staff on any proposal underthis solicitation.

5. _____I have, or within the past year have had, a financial or business relationship with theauthor(s)/staff on a proposal.

6. _____I have, or within the past year have had, a professional relationship with an applicant underreview, including serving as employee, an officer or member of the board of directors of thesubmitting organization.

7. _____ I have a financial interest in an applicant under this solicitation, which may include but is notlimited to a retirement pension, or shares of stock.

8. _____I am, or within the past year have been, a consultant/faculty/staff member of the organization,department, school, or university/institution submitting the proposal.

9. _____I have, or recently had, a collaborative relationship with a proposals author(s) or project staff.

10. _____I have within the past year received a gift or other similar gratuity from the author(s)/staff froman organization which submitted a proposal under this solicitation.

11. _____Other: Any circumstances that would cause a reasonable person with knowledge of therelevant facts to question your impartiality in the review of a proposal.

Please identify the proposal(s) in conflict:

______After reviewing the list of the applications assigned to me, I do not have a conflict with any of theproposals assigned to the panel on which I serve.

______ I agree to immediately stop work and disclose any conflict of interest to OJP if a conflict ofinterest becomes apparent as I further review the application.

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NAME:

SIGNATURE: DATE:

Specific Solicitation Name: FY10 Public Awareness and Outreach for Victims in Underserved

CommunitiesPanel Name: 7Review Session Date: From 6/4/10 to 6/25/10.

Please fax this signed form to Melissa Vroom at 301-576-8574 within 2 days of receiving thiscommunication.

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Office of Justice ProgramsU.S. Department of JusticeConfidentiality Agreement

As a peer reviewer for the Office for Victims of Crime (OVC), I agree to abide by the termsof confidentiality that is set forth in the consultant agreement and the Peer ReviewGuidelines and Instructions for the peer review panel process.

I understan d that all information in grant applications is considered Confidential Information.Confidential Information expressly includes any and all discussion or other oral or written communicationsinitiated and created in the context of, or resulting from, peer review.

I agree that I shall not at any time disclose, permit the disclosure of, release, disseminate, or transfer,whether orally, electronically, or by any other means, any part of such Confidential Information to anyperson or entity, except as expressly provided for in writing at the sole discretion of the Director of theOffice for Victims of Crime or the Directors designee.

I will not discuss the proposals, evaluations, recommendations, or names of applicants with anyindividual not involved in the peer review process.

I agree to return to Lockheed Martin Aspen Systems or destroy any written ConfidentialInformation, such as proposals and evaluation forms, at the conclusion of the review panel orafter completing Consensus Reviews.

I will not reproduce peer review material for anything other than my personal use during the peerreview process.

I further understand that the integrity of the review process is based on maintaining the confidentiality ofreviewers as well as of applicants and applicant submissions.

At no time will I discuss the names of other reviewers with any individual not involved in the peerreview process.

At no time will I put the name of a reviewer on comment and rating documents.

At no time will I contact applicants regarding their proposals for clarification or to discuss resultsof the grant review. If contacted by an applicant, I will not discuss any information pertaining toproposals under review or the results of the grant review.

NAME:

SIGNATURE: DATE:

Specific Solicitation Name: FY10 Public Awareness and Outreach for Victims in UnderservedCommunitiesPanel Name: 7

Review Session Date: From 6/4/10 to 6/25/10.

Please fax this signed form to Melissa Vroom at 301-576-8574 within 2 days of receiving thiscommunication.