Conflict of Interest Form

If you experience a situation which may create a conflict of interest or the appearance of one or experience technical difficulties with the online reporting system, please complete this form. 

If you have questions about these policies or the annual reporting process, please contact the Office of Ethics, Compliance and Privacy at 202-994-3386 or [email protected] for assistance.

Question 1
To Your Knowledge, were you or a Family Member engaged in any activities within the prior fiscal year (July 1, 2018 through June 30, 2019) that would constitute Doing Business or Seeking to Do Business with the University? If your answer is “Yes,” please provide all relevant details of each such activity, including the names of the persons or entities involved, the nature of the transaction, when the activity took place, whether the activity is currently ongoing, and the dollar amounts involved.
Question 2
To Your Knowledge, was any corporation, trust or estate, partnership, limited liability company, nonprofit organization or other entity (i) for which you, or any Family Member, serve as an officer, director, employee, partner, trustee, member, or (ii) of which you and any Family Members considered collectively are the actual or beneficial owners of more than five percent (5%) of the voting stock, profits, or other economic or ownership interest, engaged in any activities within the prior fiscal year (July 1, 2018 through June 30, 2019) that would constitute Doing Business or Seeking to Do Business with the University? If your answer is “Yes,” please provide all relevant details of each such activity, including the names of the persons or entities involved, the nature of the transaction, the percentage owned by you and your Family Members of any entity involved in the activity, when the activity took place, whether the activity is currently ongoing, and the dollar amounts involved.
Question 3
To Your Knowledge, are you or a Family Member now engaged in any activities, or planning to engage in any activities in the current fiscal year (July 1, 2019 through June 30, 2020) that would constitute Doing Business or Seeking to Do Business with the University? If your answer is “Yes,” please provide all relevant details of each such activity or plan, including the names of the persons or entities involved, the nature of the transaction, when the activity took place or will take place, whether the activity is currently ongoing, and the dollar amounts involved.
Question 4
To Your Knowledge, is any corporation, trust or estate, partnership, limited liability company, nonprofit organization or other entity (i) for which you, or any Family Member, serve as an officer, director, employee, partner, trustee, member, or (ii) of which you and any Family Members considered collectively are the actual or beneficial owners of more than five percent (5%) of the voting stock, profits, or other economic or ownership interest, now engaged in any activities, or planning to engage in any activities in the current fiscal year (July 1, 2019 through June 30, 2020) that would constitute Doing Business or Seeking to Do Business with the University? If your answer is “Yes,” please provide all relevant details of each such activity or plan, including the names of the persons or entities involved, the nature of the transaction, the percentage owned by you and your Family Members of any entity involved in the activity, when the activity took place or will take place, whether the activity is currently ongoing, and the dollar amounts involved.
Question 5
To Your Knowledge, have you or a Family Member had, during the prior fiscal year (July 1, 2018 through June 30, 2019), a Financial Interest in or been an agent of, employee of, or consultant or advisor to any entity that engages in the business of higher education or research, or the delivery of patient care services? If your answer is “Yes,” please provide all relevant details of each such Financial Interest, or relationship as an agent, employee, consultant, or advisor, including the names of the persons or entities involved, the nature of the transaction, when the activity took place, whether the activity is currently ongoing, and the dollar amounts involved.