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Prior to completing this form, please REVIEW the INFORMATION FOUND AT My Employment - Code of Conduct Website and UAPPOL Conflict Policy and Procedures. This form is used by Employees to disclose conflicts of commitment and interest.

EMPLOYEES IN THE FOLLOWING CATEGORIES MUST COMPLETE ANNUAL DISCLOSURE REPORTS:

In all of the above cases, annual reporting is required for those Employees who are “active” but who may be off campus, such as those who are seconded to other organizations or on an approved leave.

ALL EMPLOYEES MUST COMPLETE THIS FORM AT ANY TIME IF:

If you are uncertain whether you are required to complete a form, or have any questions, please contact:

Employees.Conduct@ualberta.ca

1. REPORTING INDIVIDUAL’S INFORMATION (TO BE COMPLETED IN FULL)

DISCLOSURE TYPE - CHOOSE ONE:

☐ Annual Disclosure for the Period to ; OR(including any Concurrent Activity permitted as Supplementary Professional Activity (SPA) which may constitute an actual or perceived conflict);

☐ Disclosure as a Result of Change of Circumstances from Annual Disclosure (complete Parts 1, 2-5 as applicable, and 7); OR

☐ Disclosure with respect to a New Concurrent Activity (other than that pre-approved under the Code) For the Period to (complete Parts 1, 4 , 6 and 7)

☐ I am disclosing an Actual, Perceived or Potential Conflict with this Disclosure Report (Proceed to Parts 2, 3, 4, 5)

☐ I am NOT disclosing an Actual, Perceived or Potential Conflict with this Disclosure Report (Proceed to Part 6)

REPORTING OFFICER: (The holder of the office to whom you report or who has supervisory responsibility over you. Typically, will be the Dean, Department Chair, or Manager. Reporting Officers also include Academic Staff Members and Excluded Staff Members who supervise students, trainees and/or Employees of centres or institutes.)

1. Academic Excluded Employees (Executive Members, Academic Administrators);2. Management and Professional Staff (MAPS);3. Faculty, FSOs, Librarians, APOs, TLAPS and TRAS Members;4. ATS Members who are appointed with the Contract Status of Career, Term 12 and Term 8R; and5. All other Employees, including ATS Members other than those in 4 above; and Postdoctoral Fellows, Support Staff,

Graduate and Undergraduate Students when appointed as Employees, if they:(a) make financial or hiring decisions;(b) are employed in a unit which has as its primary function the creation of legal relationships with individuals or

entities that are not part of the University;(c) may have a conflict arising out of their research activities or out of existing Concurrent Activity.

REPORTING INDIVIDUAL:

POSITION:

DEPARTMENT & FACULTY or UNIT:

NAME:

POSITION:

1. Subsequent to your annual Disclosure Report, you are re-submitting as a result of changes in circumstances.

2. You are considering a new Concurrent Activity which does not fall within the circumstances deemed to be pre-approvedunder the Code of Conduct.

DISCLOSURE REPORT FORCONFLICTS OF COMMITMENT AND INTEREST

2. PLEASE DESCRIBE THE CIRCUMSTANCES THAT MAY BE CONSIDERED A CONFLICT OF INTEREST (See examples at N/A ☐

3. PLEASE DESCRIBE THE CIRCUMSTANCES THAT MAY BE CONSIDERED A CONFLICT OF COMMITMENT:N/A ☐

4. PLEASE DESCRIBE THE NEW CONCURRENT ACTIVITY THAT YOU ARE CONSIDERING (See activities deemed pre-approved in the Code of Conduct, Page 15-16): (525 characters maximum) N/A ☐

5. PLEASE DESCRIBE ANY INVOLVEMENT IN THE EMPLOYMENT OF OR THE ACADEMIC PROGRAM OF A RELATEDPERSON (Family member or a person in a close personal relationship, See Managing Conflict in EmploymentProcedure): N/A ☐

NAME OF RELATED PERSON:

MY RELATIONSHIP TO RELATED PERSON:

DETAILS OF INVOLVEMENT IN EMPLOYMENT:

6. REPORTING INDIVIDUAL’S ACKNOWLEDGEMENTS (for those reporting on an Annual Basis)

6.1. CONSENSUAL PERSONAL RELATIONSHIPS: I understand that a conflict of interest exists when I engage in a consensual personal relationship with a student or trainee or other employee and when I am in a position to make, or influence, decisions or to take actions that might affect a student or trainee or other employee, or might reasonably be perceived to exercise power or authority over, or extend favorable or unfavorable treatment to the student or trainee or other employee. I acknowledge and understand that it is my responsibility to report/disclose such a relationship to a Manager, Chair or Dean so that any actual or perceived conflict may be addressed.

YES ☐6.2. PERFORMANCE EVALUATION, ACADEMIC PROGRAMS AND SELECTION COMMITTEES: I understand that a favorable or unfavorable bias towards an individual (employee, student or trainee) may constitute a conflict of interest when I am involved in decisions regarding their performance evaluation or academic program or when serving as a member of a selection committee considering the other individual as a candidate for a position or a student/trainee for admission into an academic program. I acknowledge and understand that it is my responsibility to report/disclose such a bias to a Manager, Chair, Dean or committee chair so that any actual or perceived conflict can be assessed in order to be appropriately managed or avoided such as stepping down, delegating, or recusing myself from such decisions.

YES ☐6.3. CONCURRENT ACTIVITY: I understand that an actual or perceived conflict of interest and/or commitment exists when I am engaged in a concurrent appointment, business, undertaking, employment, or self-employment outside my responsibilities to the university. I understand that concurrent activity must be reported except for that which is pre-approved under the Code of Conduct or that which is required to be reported as supplementary professional activity.

YES ☐ 6.4. ACCEPTING GIFTS: I understand that I cannot accept a Gift if it creates a conflict of interest. If no conflict exists, the cash value of the Gift cannot exceed $250 (not exceeding $500 per calendar year from a single source) from a person or entity with which the university does business. Acceptable gifts that are not expected to create a conflict would include those received as part of (a) a reasonable protocol; (b) a social obligation; (c) a cultural practice; (d) a normal exchange of hospitality between two persons doing business together; or (e) the normal presentation of gifts, hospitality or other benefits when participating in a public event. I understand that it is my responsibility to seek pre-approval from my Dean or Vice-President prior to accepting a gift that exceeds the limits set out above.

YES ☐

Code of Conduct Info Sheet & FAQ): (675 characters maximum)

(525 characters maximum)

(300 characters maximum)

If you require additional space for your comments in sections 2, 3, 4, and 5, please attach a separate page.

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6.5. INVITATIONS TO EVENTS (please note that employees who have the right to engage in SPA will continue to have their involvement in events wholly defined by the Collective Agreement unless the activity is an actual or perceived conflict): I understand that I cannot accept an invitation to an Event if it creates a conflict of interest. If no conflict exists, the cash value of the Event (including food, travel, entertainment, honoraria, accommodation or event tickets) cannot exceed $500 per event (not exceeding $500 from a single source and/or $8,000 per engagement when participating in an active role; and not exceeding $16,000 per year from a single source). I understand that it is my responsibility to seek pre-approval from my Dean or Vice-President prior to accepting an invitation to an Event that exceeds the limits set out above.

YES ☐7. REPORTING INDIVIDUAL’S DECLARATIONS

● I declare that the information contained in my 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 my Disclosure Report.

● I have read the University of Alberta’s Conflict Policy and related policies and procedures and the Employee’s Code ofConduct and understand my Disclosure Report is given in accordance with those policies.

● I understand that if I have indicated that I may become involved in activities (including Concurrent Activity) orrelationships that could give rise to a conflict of interest or a conflict of commitment, I shall not engage in these activitiesuntil the conflict considerations are assessed and resolved. If I have indicated that I am presently involved in activities orrelationships which could give rise to a conflict of interest or a conflict of commitment, I understand that, unless Iam ordered by the Conflict Review Officer (in consultation with the appropriate Senior Officials) to cease the activity, Imay continue the activity until such time as the conflict considerations are assessed and resolved. I understand that theorder to cease the activity shall stand until the conflict considerations are assessed and resolved.

● 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.

____________________________DATE (REQUIRED)

8. ACKNOWLEDGEMENT OF REPORTING OFFICER (OR DELEGATE, AS APPROPRIATE)MUST BE COMPLETED BY CHOOSING ONE OF THE FOLLOWING:

INITIAL and DATE WHERE APPLICABLE

No conflict reported or the identified conflict has been deemed insubstantial.

Conflict reported, and it is allowed - Reporting Individual contacted and advised that they are free to proceed with the activity or engage in the situation. As described, the conflict presents a low risk activity or situation.

Conflict reported, and is allowed - a suitable method of monitoring and managing the allowed conflict will be determined and implemented before the Reporting Individual is free to proceed with, or continue to engage in, the activity or situation. Reporting Individual will be consulted and contacted concerning steps to be taken to monitor and manage the conflict.

Conflict reported, and is not allowed because the activity/situation does not sufficiently serve the interests of the University or is not appropriately manageable or not able to withstand the test of reasonable and independent scrutiny. Reporting Individual contacted and advised that they are not free to proceed with, or continue to engage in, the activity or situation.

REPORTING OFFICERS MUST ENSURE THAT ALL DISCLOSURE REPORTS ARE AVAILABLE AND ACCESSIBLE TO UNIVERSITY OFFICIALS AND/OR AUDITORS FOR A PERIOD OF 3 YEARS.

Protection of Privacy - 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 and will be protected under Part 2 of that Act. It will be used for the purpose of determining possible conflicts of interest, assessing and managing any confirmed conflicts and managing University employees in accordance with the University's Conflict Policy – Conflict of Interest and Commitment and Institutional Conflict (UAPPOL). Direct any questions about this collection to: Human Resource Services, 2-60 University Terrace, University of Alberta. Phone: 492-4555.

SIGNATURE OF REPORTING INDIVIDUAL OR UNIVERSITY EMAIL ADDRESS _______________________________________________________________

INITIAL DATE MMM/DD/YYYY

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