Conflict of Interest Disclosure.docx
DOCX document 28 KB Posted
- Attached to
- Build Partner Resilience to Counter Proliferator State Hybrid Threats in the Nonproliferation Arena
- Opportunity number
- DFOP0016984
About this file
This document is a Conflict of Interest Disclosure form for reviewers of proposals submitted in response to a federal grant opportunity. The form requires reviewers to disclose any conflicts of interest, such as being listed as staff on a proposal, having a personal or financial relationship with the applicant, or having a collaborative relationship with the applicant outside of their government work. If a reviewer has a conflict, they must provide the name of the applicant and proposal in conflict. If a reviewer does not have any conflicts, they must indicate that as well.
The federal grant opportunity this Conflict of Interest Disclosure is related to is the "Build Partner Resilience to Counter Proliferator State Hybrid Threats in the Nonproliferation Arena" opportunity, solicitation number DFOP0016984, issued by the Department of State Bureau of International Security and Nonproliferation under the Global Threat Reduction federal grant program (CFDA 19.033). The opportunity seeks to address the erosion of nonproliferation norms and the use of WMD materials, especially chemical weapons, by proliferator states.
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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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