Fillable Printable Declaration of a Conflict of Interest Form -South Australia

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)

I have reviewed the conict of interest disclosure and;

I propose the following action is taken in relation to this matter: (Givedetailsbelow)

I believe that a plan to manage the conict of interest is not required and that no further action is necessary in relation to this

matter; or

I believe that the plan outlined in the disclosure will mitigate or remove the conict of interest but will continue to monitor

the situation; or

I cannot adequately resolve the conict of interest with the employee concerned and have referred the matter to the relevant

director / regional driector / executive director for resolution.

(Signature) (Date)

(Line Manager)

Section 3 - ENDORSEMENT BY LINE MANAGER:

Section 4: REVIEWED BY DIRECTOR / REGIONAL DIRECTOR / EXECUTIVE DIRECTOR:

Declaration of a Conict of Interest Form (for use by all DECD employees)

CO199

Page 2

(Refertoguidelinesforlinemanagerdenition)

I support the endorsed management plan

(Signature) (Date)(Relevant Director)

Iconrmacopyofthisdisclosureandendorsedmanagement

planhasbeenprovidedtotheemployee.

(Signature) (Date)

(Line Manager)

CO199

Page 3

Guideline for Declaring a Conict of Interest

Disclosure procedure

1 Save this form onto your computer. (Go

to – File; Save As; select an appropriate

folder; name the document; save).

2. Complete Sections 1 & 2 of the declaration

form and provide to your line manager as soon

as possible by sending it as an attachment

to an email titled ‘Conict of Interest’ .

3. On receipt of the declaration form, your line

manager will discuss it with you in a timely

manner. The line manager will exercise their

judgement in determining an appropriate

plan for managing the conict of interest.

4. Where necessary, the line manager will seek

the advice of the Director / Regional Director

/ Executive Director or Ethical Conduct Unit

(ECU). Prior to doing so, the line manager

will advise the employee of their intention.

You and your line manager should agree on

a plan for managing the conict of interest.

5. Where a plan cannot be agreed upon, the matter

should be referred to the Director / Regional

Director / Executive Director. The management

plan should be recorded in Section 2 of the form.

6. The form, including the conict of interest

management plan, is to be provided to the

Director / Regional Director / Executive Director

who will either endorse the management plan

or propose alternative action in Section 4 of the

form and keep a copy for consistency of records.

7. The endorsed form will be forwarded to

your line manager for condential storing.

It is required that employees are provided

with a signed copy for their records.

8. Advice from the Ethical Conduct Unit can

be sought at any stage of the process.

Condentiality of disclosure

DECD will seek to ensure that condential disclosures

are protected from misuse. Conict of interest

disclosures will be treated as condentially as possible,

within the requirements of the law.

The relevant line manager / director in receipt of a

disclosed conict of interest will exercise their judgment

about the level of condentiality necessary to manage

the conict. If in doubt, advice should be sought from

the Ethical Conduct Unit.

Conicts of interest denitions

Conicts of interest can be pecuniary (involving nancial

gain or loss) or non-pecuniary (based on animosity,

friendship or family connections). A conict of interest

can also arise from avoiding personal losses as well

as gaining personal advantage, nancial or otherwise.

Conicts of interest can be actual, perceived, or

potential:

Actual conict involves a direct conict between

current duties and responsibilities and existing private

interests.

Potential conict arises where private interests could

conict with ofcial duties.

Perceived conict exists where it could be perceived,

or appears, that private interests could improperly

inuence the performance of duties - whether or not

this is in fact the case.

Line manager denition

A line manager within this context shall mean a

Principal, Preschool Director, or Regional Director

responsible for a school or preschool, or a Manager

and/or Director responsible for a site/business unit or

ofce.

Itisimportanttonotethatconictsofinterestarenotwronginthemselves.Itishowaconictofinterest

ismanagedthatisimportant.

Therefore,fulldisclosureofanyconictofinterest,whetheractual,potentialorperceivedmustbemade

totheappropriatelinemanagerassoonasreasonablypractical.

For further information and advice, please contact the Ethical Conduct Unit on 8226 1342 or via email at:

[email protected].au