Please complete the following questions, and submit this form to the Country Director/Executive Director.
Please complete the following questions, and submit this form to the Country Director/Executive Director.
1. Are you or a member of your immediate family (spouse, parent, children, siblings) an officer, director, trustee, partner (general or limited), employee or regularly retained consultant of any company, firm or organization that presently has business dealings with ORGANIZATION X Ghana or which might reasonably be expected to have business dealings with ORGANIZATION X Ghana in the coming year?
Yes
No
If yes, please list the name of the company, firm or organization, the position held, and the nature of the business which is currently being conducted with ORGANIZATION X Ghana or which may reasonably be expected to be conducted with ORGANIZATION X Ghana in the coming year:
2. Do you or does any member of your immediate family have a financial interest, direct or indirect, in a company, firm or organization which currently has business dealings with ORGANIZATION X Ghana or which may reasonably be expected to have such business dealings with ORGANIZATION X Ghana in the coming year?
Yes
_No
If yes, please list the name of the company, firm or organization, the nature of the interest and the name of the person holding the interest, and the nature of the business which is currently being conducted with the Organization or which may reasonably be expected to be conducted with ORGANIZATION X Ghana in the coming year:
3. Do you or does any member of your immediate family have a financial or personal interest in an entity in which ORGANIZATION X Ghana has a financial or other vested interest (for example a client organization or LCB).
Yes
No
If yes, please provide details below:
4. Have you or an immediate family member accepted kickbacks, gifts, gratuities, lodging, dining, or any other benefit as a result of the business of ORGANIZATION X Ghana?
Yes
No
If yes, please provide details below:
5. Do you run a business whereby ORGANIZATION X employees are some of your clients
e.g. money lending, clothing etc?
Yes
No
If yes, please provide details below:
6. Do you or your immediate family members have direct or indirect interests in a company or organization that provides services similar to those of companies or organizations sub- contracted by ORGANIZATION X? For example Consultancy firms, office supplies companies, etc.
Yes
No
If yes, please provide details below:
7. Are you involved in any part-time employment or activities that require from your work week? For example part-time consultancy, part-time lecturing etc.
Yes
No
If yes, please provide details below:
8. Other, please use this space to declare any other type of actual, perceived or potential conflict of interest:
Please provide details below:
Please add additional pages as needed.
If any material changes to the responses provided on the annual disclosure form occur before the next form is due, the employee is required to update the information on this form in writing, and submit the update to the Country Director, ORGANIZATION X Ghana.
Employee Signature Date
Management Assessment: Conflict of Interest
No Conflict of Interest
Potential Conflict Exists