South Dakota State University
Conflicts of Interest Disclosure Form

Employee Information

Required fields marked with a red asterisk (*).

Name *

Position Title: *

Department: *

Campus Phone:

Email: *

Institution ID (AID or ID Number on e-paystub): *

DISCLOSURE AND CERTIFICATION:

1. In the coming year, do you anticipate: (a) entering into agreements to teach for a non-Regental institution; or (b) providing similar services to the public through an outside entity that you also provide as an employee of your institution? *

Yes

CONFLICTING SERVICE COMMITMENTS: (APPROVAL SHOULD BE OBTAINED PRIOR TO ENGAGING IN SUCH ACTIVITIES. IF YOU ARE ALREADY ENGAGING IN THESE ACTIVITES, PLEASE DISCLOSE THE INFORMATION AT THIS TIME AND THE REQUIRED APPROVAL WILL BE SOUGHT). List each outside businesses or organizations and a brief description of the service(s) to be provided: *

2. Do you, your spouse, or any adult with whom you live and commingle assets (“immediate family member(s)”: (1) receive income or other compensation from any source other than the state’s public system of higher education; (2) have an ownership interest exceeding 5% or $5,000 in value in any business, company or other entity; or (3) serve on the board of directors of a for-profit business, company or other entity? *

Yes

3. Could the financial interest identified in question 2 be reasonably perceived by others to influence institutional business, research or other decisions that you or others whom you supervise make on behalf of the institution (i.e., your professional duties appear to be related to your financial interest or involve making decisions or supervising others who make decisions that could affect your financial interest or the source from which your financial interest stems)? Note: it is the potential perception of influence and not actual influence that triggers a positive response to this question. *

Yes

Person(s) with financial interest(s): *

Financial interest: List each financial interest that could be reasonable perceived by others to influence institutional business, research or other decisions on behalf of the institution made by you or others whom you supervise.

Financial interest held by Immediate Family Member: *

Financial interest held by Employee: *

4. Do your professional duties (i.e., scope of employment/official duties with the institution) include: (1) approving, awarding, or administering contracts; (2) recommending contracts for approval or award; or (3) supervising a person who approves, awards, or administers contracts? *

Yes

5. An additional disclosure and approval is required if: (i) any of the entities in which you or your immediate family member(s) have a financial interest (ii) engage in a transaction with the institution (iii) where something of value is exchanged and (iv) the transaction falls within the purview of your professional/official duties. Has any such transaction occurred, or do you anticipate any such transactions occurring? *

Yes

FINANCIAL INTEREST: List each business, company or other entity in which you have, or an immediate family member has, a significant financial interest that has or may enter into a transaction falling within the purview of your professional/official duties with the institution: *

Employee Signature

Employee Signature *

clear

Date: *

By submitting this form I certify that I am the employee listed above and that the information contained herein is true, accurate and complete to the best of my information, knowledge, and belief. Providing false or misleading information may be grounds for disciplinary action.

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South Dakota State UniversityConflicts of Interest Disclosure Form

Employee Information

DISCLOSURE AND CERTIFICATION:

Employee Signature

South Dakota State University
Conflicts of Interest Disclosure Form