Conflict of Interest Disclosure.docx
DOCX document 28 KB Posted
- Attached to
- Nonproliferation Scientist Engagement Program
- Opportunity number
- DFOP0016994
About this file
The provided document is a Disclosure of Conflict of Interest form for reviewers of applications submitted to the U.S. Department of State's Bureau of International Security and Nonproliferation. It requires reviewers to disclose any conflicts of interest, such as being listed as staff on a proposal, having a personal or professional relationship with the applicant, or having a collaborative relationship outside of their government work. Reviewers must provide the name of the applicant and proposal in conflict or indicate if they have no conflicts. This form is related to the Nonproliferation Scientist Engagement Program (NSEP), a cooperative agreement funding opportunity focused on providing near-term capacity-building support to civilian scientists and technical experts with relevant expertise who are geographically displaced or financially vulnerable due to the Russia-Ukraine conflict. The NSEP falls under the Global Threat Reduction program administered by the Department of State's Bureau of International Security and Nonproliferation.
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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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