Conflict of Interest Disclosure.docx
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- Opportunity number
- DFOP0016988
About this file
This document is a Disclosure of Conflict of Interest form to be completed by a reviewer of proposals submitted in response to a federal grant opportunity. The form requires the reviewer to disclose any conflicts of interest they may have with the proposals assigned to them for review. Potential conflicts include 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 outside of the reviewer's government work. The reviewer must provide the name of the applicant and proposal in conflict or indicate they do not have a conflict with any of the assigned proposals.
The related federal grant opportunity is titled "Build Partner Capabilities to Protect Critical Advanced and Emerging Technologies" and 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). The opportunity seeks to address the risk of malign actors acquiring critical advanced and emerging technologies, data, intellectual property, and talent through legal and illegal means that can be leveraged for military end uses.
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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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