UConn Health Board of Directors Conflict of Interest Disclosure

UConn Health Board of Directors Conflict of Interest Disclosure Form 2021

All members of the UConn Health Board of Directors are required to submit a Conflict of Interest Disclosure form annually. In addition, if a new potential conflict of interest arises during the year, members are required to submit an additional form to update their interests and relationships. Information submitted through this form will be shared with the Conflicts of Interest Sub-Committee for review and to determine if a management plan is required. Should you have any questions regarding this form, please contact Deb Kaufman at dkaufman@uchc.edu.

Name
First Last
I, my spouse (domestic partner or partner in a civil union), and/or my dependent children have the following interests or relationships (check all applicable):*
- Have a financial interest (ownership interest, salary or other payment for services, intellectual property rights), with an entity that does business with UConn Health, might do business with UConn Health, or is a competitor of UConn Health.
- Hold a position of officer, director or trustee with an entity that does business with UConn Health, might do business with UConn Health, or is a competitor of UConn Health.
- Are paid by UConn Health as employee, contractor or in another capacity.
- None of the Above
If you are disclosing a financial interest or relationship on behalf of yourself, your spouse or your dependents, please provide detailed information regarding each potential financial interest and/or relationship that may present a conflict of interest with your membership on the Board of Directors at UConn Health.
Please attest to the following statements indicating your understanding of your responsibility related to conflicts of interest as a member of the Board of Directors at UConn Health.*
- Select All
- I have read and understand the Conflict of Interest Policy for the Members of the University of Connecticut Health Center Board of Directors ;
- If and when an issue arises in front of the Board of Directors that I believe I may be perceived to have a conflict of interest in, I will notify the chair of the Board, chair of the subcommittee, or a member of the BoD CoI committee and declare my potential CoI;
- I agree to cooperate with the UConn Health BoD CoI committee in determining whether a management plan for any conflicts of interest are necessary as well as agree to comply with such a plan.
Comments
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