Conflict of Interest Disclosure.docx
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- Opportunity number
- DFOP0016995
About this file
This document is a Disclosure of Conflict of Interest form for a federal grant reviewer. It requires the reviewer to disclose any potential conflicts of interest 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 collaborative or professional relationship with the applicant organization. The reviewer must either identify the specific proposal(s) in conflict or indicate they have no conflicts. This form is related to a federal grant opportunity titled "Countering DPRK and Iran's WMD, UAS, and Missile Proliferation" managed by the Department of State's Bureau of International Security and Nonproliferation under the Global Threat Reduction program. The grant provides funding through cooperative agreements to support capacity-building programs, research, and other efforts to detect and disrupt DPRK's weapons of mass destruction proliferation activities.
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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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