Conflict of Interest Disclosure.docx
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- Opportunity number
- DFOP0016986
About this file
The provided document is a Disclosure of Conflict of Interest form for a reviewer of applications submitted to the [BUREAU] under a federal grant opportunity. The form requires the reviewer to disclose any potential conflicts of interest, such as being listed as a staff member, having a close personal or financial relationship with the applicant, or having a collaborative relationship with the applicant outside of their government work. The reviewer must indicate if they can review the proposal objectively or if they feel their involvement would be problematic. The document is related to the federal grant opportunity "Advancing Nuclear Safety, Security, and Nonproliferation through the FIRST Program", which is administered by the Department of State's Bureau of International Security and Nonproliferation under the Global Threat Reduction program (CFDA 19.033). The program provides technical capacity-building support to potential and current nuclear energy countries to enhance secure, safe, and proliferation-resistant deployment of small modular reactors (SMRs) or other advanced reactor designs.
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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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