Conflict of Interest Form

Who must complete this form? Any workplace participant or BOM director (e.g. employees, contractors/consultants) assessed by Community Care TASMANIA as warranting a declaration on the basis of potential, perceived or actual conflict of interest risk. This form must be completed: At the time a conflict of interest is identified. At any time instructed by the CEO or their delegate

Employee's Name:

Position:

Supervisor's Name:

1. OUTSIDE EMPLOYMENT OR SERVICE:

Do you have any outside employment or provision of outside services, current or planned, which may pose a conflict of interest, as defined in the Conflict of Interest policy? If yes please explain. *

Yes	No
If yes, please explain: If yes, please explain:

2. OUTSIDE INTERESTS, FINANCIAL AND OTHER

Do you have any interests or positions which you or your family, directly or indirectly, hold in any outside concern from which Community Care TASMANIA secures, or will secure goods or services, or that provides services competitive with the company? If yes please explain. *

Yes	No
If Yes, please explain: If Yes, please explain:

Do you have any interests or positions which you or your family, directly or indirectly, hold in any outside concern from which Community Care TASMANIA secures, or will secure goods or services, or that provides services competitive with the company? If yes please explain. *

Yes	No
If Yes, Please explain: If Yes, Please explain:

3. GIFTS, GRATUITIES, SERVICES AND ENTERTAINMENT:

Have you accepted or given any gifts, gratuities, services or entertainment which have a cumulative market value of $100 or more in one fiscal year or an individual market value of $25 or more that you or your family have accepted that might be reasonably regarded as influencing or having the potential of influencing your judgment or actions concerning business of the company? If yes please explain. *

Yes	No
If Yes, Please explain: If Yes, Please explain:

4. FAMILY OR BUSINESS RELATIONSHIP CONFLICTS:

Do you have any family or business relationships with Board members, clients, key personnel and/or any other employee of the company? *

Yes

No No

If yes, you have any family or business relationships with Board members, clients, key personnel, and/or any other employee of the company please explain below: *

5. OTHER::

Are there any other activities in which you or your family are engaged that might be regarded as conflicts of interest? If yes please explain. *

Yes	No
If Yes, please explain: If Yes, please explain:

Employee Declaration

Employee Signature: *

clear

Date: +

Action by CEO or Delegate

Describe the action proposed to mitigate the real or perceived conflict which has been disclosed and the reasons for the decisions: Actions taken or to be taken include: (Type in space below)

The above action has been discussed with the employee and is appropriate to resolve the real or apparent conflict of interest disclosed above:

Signature of CEO or Delegate:

clear

Employee Endorsement Signature:

clear

Date: +