Conflict of Interest Disclosure.docx
DOCX document 28 KB Posted
- Attached to
- Build Partner Capabilities to Counter the Russian Federation's Chemical and Biological Threats
- Opportunity number
- DFOP0016992
About this file
This document is a Disclosure of Conflict of Interest form for reviewers of proposals submitted to the U.S. Department of State's Bureau of International Security and Nonproliferation. It requires reviewers to disclose any conflicts of interest they may have with the proposals they are assigned to review, such as being listed as staff on a proposal, having a close personal or financial relationship with the applicant, or having a recent collaborative or professional relationship with the applicant. Reviewers must provide the name of the applicant and proposal for which they have a conflict. If they do not have any conflicts, they can indicate that as well. This form is tied to a specific funding opportunity titled "Build Partner Capabilities to Counter the Russian Federation's Chemical and Biological Threats" under the Department of State's Global Threat Reduction program.
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Text version
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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