Conflict of Interest - Disclosure Form
DOCUMENT 2 FOI 20/21-0857
General details
- Employee’s Surname
- Given Name/s
- Position
- Branch / Location
- Manager’s Name
Declaration of interests
Describe the private interests that have the potential to impact on your ability to carry out, or be seen to carry out, your official duties impartially and in the public interest. (Describe your private interests and/or associations)
[redacted]
Role at the NDIA
Describe the expected roles/duties you are required to perform. (Describe the duties you are required to perform)
[redacted]
Identifying the conflict of interest
The conflict of interest has been identified as: (Please select applicable conflicts below)
- A real conflict of interest
- An apparent conflict of interest
- A potential conflict of interest
- Financial interest
- Personal interest
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Employee Declaration
Describe the actions you have taken to avoid any real or apparent conflict of interest:
I declare that the above details of my private interests are correct to the best of my knowledge and am aware of my responsibilities to take reasonable steps to avoid any real or apparent conflict of interest in connection with my public service employment and to advise my manager of any relevant changes in my personal circumstances.
Signature: Date:
Action by Manager
Describe the action proposed to mitigate the real or apparent conflict which has been disclosed and the reasons for the decisions:
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 manager: Date:
Employee endorsement of proposed actions
Signature of employee: Date:
Approval by Regional Manager or General Manager (for National Office teams)
Approved – Please discuss
Signature of RM / GM: Date:
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