Conflict of Interest Disclosure Form

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Conflict of Interest Disclosure - BCPSA 102a

Use this form to disclose a situation in order for your manager/supervisor (or an ethics advisor) to assess whether it may be a conflict of interest.

If you are unsure whether you the need to disclose a conflict of interest, speak to your manager or an ethics advisor. If you have any questions refer to the Conflict of Interest Guidelines (PDF, 426 KB)

Disclosure must take place in a timely manner – within 30 days - from the time you become aware of a possible conflict.

NOTE: Ensure the completed form is submitted in a single session: entries and uploads cannot be saved for later editing and submission.

Before you start:

Review the Standards of Conduct to understand how a conflict of interest is defined
Make a list of your job duties or responsibilities
Make a list of any personal interests that you think might be in conflict with your duties
If your disclosure will include the personal information of a third party, you must complete a Third Party Authorization for Collection and Use of Personal Information (PDF, 208 KB) to attach to this disclosure

Form submission

Once you have completed this form use the Submit button at the bottom. A copy of this form will be sent to you and your manager (or your ethics advisor)

This form is intended for BC Public Service employees. If you are political staff please use the Disclosing a Conflict of Interest: Political Staff Guideline & Disclosure Form (PDF, 270 KB).

The Standards of Conduct define a conflict of interest as a situation where an employee’s private affairs or financial interests are in conflict, or could result in the perception of conflict, with the employee’s duties or responsibilities in such a way that:

the employee’s ability to act in the public interest could be impaired; or
the employee’s actions or conduct could undermine or compromise:
- the public’s confidence in the employee’s ability to discharge work responsibilities; or
- the trust that the public places in the BC Public Service

A conflict of interest therefore involves a conflict between the public duty and private interests of an employee, in which the private interests could influence the performance of their job duties, or in which an employee uses their office for personal gain.

Employees are required under the Public Service Oath Regulation and Standards of Conduct to arrange their private affairs to avoid conflicts of interest, which include real, perceived or potential conflicts, and to disclose possible conflict situations to their manager or ethics advisor. Please see the Standards of Conduct for more information about your conflict of interest obligations.

I have read and understood the Standards of Conduct section concerning conflicts of interest

I am disclosing what is or may be a conflict of interest.

I agree to cooperate with the employer regarding requests for additional information directly related to and necessary to address this possible conflict, and to inform the employer of any changes to the facts or other relevant details directly related to this conflict

Please provide the following:

1. Your job duties or activities relevant to the possible conflictMandatory field is incomplete. Please review the form.

2. Your private interests relevant to the possible conflictMandatory field is incomplete. Please review the form.

3. A description of the steps you will take to mitigate this possible conflictMandatory field is incomplete. Please review the form.

The third party might be the employee’s spouse, another family member, a friend, or business associate whose interest is related to the conflict being disclosed. To ensure government may collect and use the personal information of a third party that relates directly to and is necessary for an assessment of a conflict of interest, the Freedom of Information and Protection of Privacy Act requires the third party to authorize the collection of their personal information. If you are making a disclosure that involves the personal information of a third party, you must obtain their signature authorizing the collection and use the information by the employer.4. Are you disclosing personal information related to a third party? If you are disclosing personal information of a third party you must obtain their permission before making your disclosure. You may also attach other relevant documents.YesNoMandatory field is incomplete. Please review the form.

Attach a completed Third Party Authorization for Collection and Use of Personal Information (PDF, 208 KB) to this disclosure and/or other relevant documents.

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Notice of Collection of Personal Information

The information required by this form and the Public Service Oath Regulation and Standards of Conduct is collected for the purpose of assessing whether the circumstances disclosed constitutes a real, perceived, or potential conflict of interest. Managing conflict of interest concerns in favour of the public interest is necessary to maintain public trust and confidence in the integrity of the BC Public Service.

This information is collected in accordance with section 26 of the Freedom of Information and Protection of Privacy Act (FOIPPA). Once a conflict of interest matter is resolved, this form will be included on the employee’s personnel file held by the BC Public Service Agency. All information collected, used and disclosed for the purposes of assessing a possible conflict of interest will be treated in strict accordance with FOIPPA. Questions about the management of the information can be directed to the Director, Policy and Research Branch, BC Public Service Agency, PO BOX 9404, Victoria, BC, V8W 9V1, (250) 952-6000.

Employee Declaration:

I certify that the information I am providing with this form is to the best of my knowledge complete and accurate. I acknowledge that misrepresentations or material omissions may be a breach of the Standards of Conduct and grounds for discipline.

Sign with your mouse or finger on touch screen devices.Employee Signature

Mandatory field is incomplete. Please review the form.Sign with your mouse or finger on touch screen devices.

Date

Employee NumberMissing or incorrect value

Employee NameMissing or incorrect value

Employee EmailMandatory field is incomplete. Please review the form.A copy of this submission will be sent to this email

Manager NameMandatory field is incomplete. Please review the form.

Manager EmailMandatory field is incomplete. Please review the form.

A copy of this submission will be sent to this email. If you do not want to submit this to your manager, you can submit to your ethics advisor.

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Conflict of Interest Disclosure Form

Conflict of Interest Disclosure - BCPSA 102a

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Conflict of Interest Disclosure Form

Conflict of Interest Disclosure - BCPSA 102a

Instructions

1. Employee Acknowledgements

2. Employee Disclosure Statement

3. Employee Signoff and Submission

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