Conflict of Interest Disclosure.docx
DOCX document 28 KB Posted
- Attached to
- Countering WMD and UAS Threats in Iraq
- Opportunity number
- DFOP0016991
About this file
This document is a Conflict of Interest Disclosure form that federal grant reviewers must complete when reviewing applications submitted to the U.S. Department of State's Bureau of International Security and Nonproliferation. The form requires the reviewer to disclose any 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 outside of their government work. Reviewers must identify any proposals they cannot review objectively and sign the form to certify their disclosures.
The related federal grant opportunity is for the "Countering WMD and UAS Threats in Iraq" program, which is funded through the State Department's Global Threat Reduction program (CFDA 19.033). The grant aims to address the continued threat posed by ISIS and other terrorist groups in Iraq, as well as the increasing use of unmanned aerial systems (UAS) attacks by Iran-backed militias. The funding instrument is a cooperative agreement, and the solicitation number is DFOP0016991.
C of I Disclosure
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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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