Conflict of Interest Declaration

Instructions

Complete this form if there is any real or potential conflict of interest (person with conflict)
Complete this form if you work for another organisation
Management to determine and record how to manage any conflict
Details must be recorded in the Conflict of Interest Register

Name Staff Member *

Role/Position *

Do you have a Conflict of Interest *

YesNo

Has the conflict occurred? *

YesNo

When did the conflict occur or is likely to occur?

List potential, perceived or real conflict of interest

Identify what the conflict of interest involves

List other employers

Name of staff member *

Date signed *

Signature *

Draw signature|Type signatureClear

Describe how the matter was dealt with

List any follow up actions required

Name Representative Strength In Care

Date signed

Signature Strength In Care

Entered on Register on: