Conflict of Interest Disclosure.docx
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- Opportunity number
- DFOP0016990
About this file
This document is a Disclosure of Conflict of Interest form for reviewers of proposals submitted in response to a federal grant opportunity. The form requires reviewers to disclose any potential conflicts of interest, such as being listed as staff on a proposal, having a close personal or financial relationship with the applicant, or having a collaborative relationship with the applicant. Reviewers must provide the name of the applicant and proposal that presents the conflict. If no conflicts exist, the reviewer indicates this as well. The related federal grant opportunity is titled "Building Partner Capacity to Counter Chemical Weapons Threats" and is funded through the Global Threat Reduction program of the U.S. Department of State's Bureau of International Security and Nonproliferation. The grant supports efforts to reduce the threat posed by terrorist organizations or states of concern related to chemical weapons.
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U.S. Department of State
DISCLOSURE OF CONFLICT OF INTEREST
As a reviewer of applications submitted to [BUREAU], I find the following conflicts with proposals that I have received to review:
_____ I am listed as a staff member, consultant, or advisor on a proposal.
_____ I have close personal or familial relationship with the author or staff on a proposal.
_____ I have or recently (i.e., within last year) had a financial relationship with the author or staff on a proposal involving grants, publications, presentations, etc.
_____ I have or recently had a professional relationship with an applicant under review, including serving as an officer or having served as a past officer or as a member of the board of directors of the submitting organization.
_____ I am or recently been a faculty or staff member of a department, school, university, or organization submitting a proposal.
_____ I have or recently had collaborative relationship (outside of my USG work) with a proposal’s author or project staff.
____ I cannot review a proposal objectivity or I feel that others would view such action to be problematic.
Provide the name of the applicant and proposal in conflict: ______________________________
__________ I do not have a conflict with any of the proposals assigned to the panel on which I serve.
NAME (Print) _________________________________________
SIGNATURE __________________________________________ DATE __________
Panel Name/NOFO Title: ________________________________
Panel Dates: _________________________________________
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