Institute of Continuing Legal Education Staff Disclosure Form

CONFIDENTIAL
Institute of Continuing Legal Education
Staff Disclosure Form for Potential Conflicts of Interest/Conflicts of Commitment
Name: __________________________________________EMPLID:_________________
I have read the ICLE Policy on Conflicts of Interest/Conflicts of Commitment for Staff, and I am filing this
form in accordance with the Policy to disclose a possible conflict of interest or conflict of commitment.
(Please describe the potential conflict below).
Signature of Staff Member: __________________________________________ Date: __________
Once completed this form should be submitted to your supervisor for transmittal to the Administrative Director.
Name and Signature of Supervisor: ____________________________________ Date: __________
Review of Disclosure by Administrative Director:
1. Does a conflict exist? ___ No ___ Yes (if yes, proceed to question 2)
2. If conflict exists, is it manageable? ___ No ___ Yes (if yes, proceed to question 3)
3. If conflict is manageable describe the management plan in the space provided below.
Name and Signature of Administrative Director: ________________________________ Date: _________
After review of the disclosure a copy of this form should be returned to staff member for signature (below)
to confirm acknowledgement of the decision that was reached.
Signature of Staff Member: ____________________________________________ Date: _________