Conflict of Interest Disclosure.docx
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- Opportunity number
- DFOP0016993
About this file
This document is a Conflict of Interest Disclosure form to be completed by reviewers of proposals submitted for a federal grant opportunity. It requires reviewers to disclose any conflicts of interest they may have with the proposals assigned to them, such as being listed as staff on a proposal, having a close personal relationship with the applicant, or having a recent financial or professional relationship with the applicant. Reviewers must provide the name of the applicant and proposal in conflict, or indicate that they do not have a conflict with any of the assigned proposals. This disclosure is required for the "Countering the Russian Federation's Sanctions Evasion Activities" grant opportunity, which is funded by the U.S. Department of State's Bureau of International Security and Nonproliferation under the Global Threat Reduction program (CFDA 19.033).
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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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