Conflict of Interest declaration form - National Research Council Canada

Instructions

Please read this form with reference to the NRC Conflict of Interest Policy both as someone joining NRC for the first time and as part of a regular review of your outside interests.
Check the corresponding box(es) when you determine that a potential, apparent or actual conflict of interest situation could exist between your official duties and other interests.
For any checked item, please provide details and describe the nature of the matter in the space provided.
As indicated in your NRC Letter of Offer, you are NOT REQUIRED to submit this form if after reviewing it and the NRC COI Policy (2007) you determine that you have nothing to declare.
The Conflict of Interest Declaration Form is intended to facilitate communication between you, your management and the NRC Secretary General’s Office (NRC-SGO). Declarations submitted to the NRC-SGO are assessed to confirm whether or not the situation constitutes a potential, apparent, or actual conflict between your personal interests and your official duties and/or responsibilities within NRC. If such a conflict is found to exist, a plan is developed to resolve the situation. Early involvement of your current or potential management in discussions can assist in the assessment and resolution of the conflict.
Visiting Workers: You are to comply with the intent of the NRC COI Policy, and any related conditions indicated in your agreement with NRC, but you are not required to submit this form to the NRC-SGO.
If you prefer filing this form on paper, you can print the PDF version of the Conflict of Interest declaration form.

Protected when completed.

Personal information

First name: (required) Last name: (required) Email: (required) Institute/Branch/Program: (required) Work Location (City/Province): (required) Position Title: (required)

Status

Status Potential Employee Current employee (includes employees who are seconded out and employees in new positions) Former employee Member of NRC Advisory Committee or Board Other

Specify (Other status): Are you or were you in the past year in one or more of the “designated positions” listed below?

Assets and Liabilities

Do you possess, or are you considering acquiring, any relevant (with respect to the NRC COI Policy)

Do you possess, or are you considering acquiring, any relevant (with respect to the NRC COI Policy) a) publicly traded securities of corporations and/or foreign governments, and/or self-administered Registered Retirement Savings Plans (RRSPs), or Registered Education Savings Plans (RESPs) that are composed of these securities, but which are held directly and not through units in mutual funds? b) narrowly focused, “sector” mutual funds i.e. mutual funds that invest primarily in companies engaged in activities which are closely related to your area of professional expertise? c) interests in partnerships, proprietorships, joint ventures, private companies and family businesses, in particular those that own or control shares of public companies or that do business with the government? d) commercially operated farm businesses? e) realty (land, buildings, etc.) that is not for your private use or for the private use of a family member? f) commodities, futures and/or foreign currencies held or traded for speculative purposes? g) assets placed in trust or resulting from an estate of which you are a beneficiary? h) secured or unsecured loans granted to persons other than members of your immediate family? i) patents or royalty earning arrangements? j) direct and/or contingent liabilities in respect of any of the assets described in this section?

Description of the situation regarding assets and liabilities

For each response regarding assets and liabilities, please specify the question being addressed.

Outside employment or activities

Do you participate or are you considering participating in any of the following?

Do you participate or are you considering participating in any of the following? k) outside employment with organizations that have or may have business interests relevant to NRC programs and services? l) activities that might subject you to demands which are incompatible with your official duties and/or cast doubt on your ability to perform your duties in a completely objective manner? m) Are you, or are you considering becoming a senior official or member of the board of directors of a company or for-profit organization that has or might have business dealings with the government, particularly with NRC? n) Have you been invited to serve or are you considering serving on an advisory committee and/or board of a non-profit organization, association, or other similar entity that has or might have business dealings with the government, particularly with NRC? o) Are you, or are you considering becoming involved in any political activity?

Description of the situation regarding outside employement or activities

For each response regarding outside employement or activities, please specify the question being addressed.

Benefits

Benefits p) Have you been offered or solicited any gifts, hospitality, honorariums, travel and/or accommodations or other benefits in relation to your official duties or the outside activities listed above ? q) Have you been offered any professional awards/prizes in relation to your position with NRC, from non-government entities ?

Description of the situation regarding benefits

For each response regarding benefits, please specify the question being addressed.

Relationships

Relationships r) Have you or might you be engaged in any decision-making related to a staffing process in which family or friends may be involved? s) Have you or might you be engaged in making recommendations or decisions that will result in a financial award or other benefit to an external party where family or friends may be involved? t) Have you or might you be directly engaged in providing friends, family, or organizations with which they are associated with access to government programs, services, or contracts? u) Have you or might you knowingly provide former NRC or other former government employees with what could be perceived as privileged access to government programs and services ?

Description of the situation regarding relationships

For each response regarding relationships, please specify the question being addressed.

Other

Other v) Do you have anything else to declare that is not addressed in this form?

Description of the situation regarding other instances

For each response regarding other instances, please specify the question being addressed.

Declaration – Privacy Act Statement

The information you provide on this document is collected under the authority of the National Research Council Act and NRC's authority as a separate employer under the Financial Administration Act, for the purpose of maintaining information about real or potential conflict of interest situations. It will be stored in personal information bank number NRC/P-PE-801. Personal information that you provide is protected under the provisions of the Privacy Act, and you may review it for accuracy in accordance with the provisions of this law.

I ACCEPT THESE TERMS

For additional information, please consult the NRC Conflict of Interest Policy

You should promptly submit a revised declaration whenever there is a relevant change in your personal situation or your official responsibilities.