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Declaration of a Conflict of Interest Form -South Australia

1 Declaration of a Conflict of Interest Form -South Australia
2 Declaration of a Conflict of Interest Form -South Australia
3 Declaration of a Conflict of Interest Form -South Australia
Please return to: Line Manager CO199
Updated 03/13
Page 1
Declaration of a Conict of Interest Form (for use by all DECD employees)
Current
Role
ACTUAL
I hereby agree to:
• updatethisdisclosurethroughouttheperiodofmyemploymentwiththeDECDonanannualbasisoruntilsuch
timeastheconictceasestoexist;and
• co-operateintheformulationofa‘conictmanagementplan’asrequired;and
• complywithanyconditionsandrestrictionsimposedbyDECDtomanage,mitigateoreliminateany
actual,potentialorperceivedconictofinterest.
Location
Person ID
Telephone
Given
Name(s)
Family
Name
E-mail
I hereby declare a conict of interest:
POTENTIAL
PERCEIVED
ThePublicSector(HonestyandAccountability)Act1995describesthedutyofemployeesinrespectofconictsofinterestand
theirresponsibilitytodiscloseinwritingthenatureoftheinterestandtheconictorpotentialconict.Preventionofaconictof
interest,whetheractual,potentialorperceived,accordswiththePublicSectorAct2009andisacriticalelementoftheCodeof
EthicsfortheSouthAustralianPublicSector.ThisformistobecompletedbyanyDECDemployeewhohasareal,perceivedor
potentialconictofinterestinundertakingtheirdutiesandobligations.
A copy ofthe completed and signed form, including the management plan, is to be condentially stored on the employee’s
personnelleinDECD.Theemployee’sconictofinterestmanagementplanshouldbereviewedatleastannuallyduringthe
performancereviewprocess.ForfurtherinformationandguidancerefertotheDECDConictsofInterestnewsletters(parts1
and2),addendums,FAQsandreferencesat:http://www.decd.sa.gov.au/hr/les/links/Newsletter_7__Conicts_of.pdf
(Signature of Employee) (Date)
Section 1: EMPLOYEE DETAILS
Section 2: EMPLOYEE’S DISCLOSURE
Please provide a brief outline of the nature of the conict. Refer to the ‘Managing Conicts of Interest in the
Workplace’ newsletter and FAQs for further information and guidance.(AvailableontheDECDwebsite)
Please detail a ‘conict management plan’ in consultation with your line manager to manage / resolve the
conict.
Conict Details:
Management
Plan:
(Refertoguidelinesforconictsofinterestdenition)
Page 1/3
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