Research and Capacity Building, Island Health
Submission Deadline: Monday, November 16th, 2015
Title: University: Department:
Proposed Island Health Program focus:
Proposed Island Health Lead(s):
Summary of Proposed Research Project(s):
Appendix B: Declaration of Stakeholder Affiliation/Conflict Of Interest
Capitalized terms used in this Conflict of Interest Declaration (“Conflict Declaration”) shall have the meaning ascribed thereto in the Scholar in Residence Competition of which this declaration forms a part. Island Health requires that each Applicant, if they believe they are in a conflict of interest, to complete this Conflict Declaration as part of its Proposal in accordance with the Scholar in Residence Competition.
The purpose of this conflict of interest declaration is to advise Island Health of any Conflict of Interest it may have in respect to the Scholar in Residence role at Island Health. Upon the disclosure of a Conflict of Interest, Island Health will make a decision as to whether it should disqualify an Applicant. Accordingly, full disclosure as to any Conflict of Interest by each Applicant is required. The accurate disclosure of a Conflict of Interest will result in an analysis by Island Health, where the failure to disclose a Conflict of Interest may result in immediate disqualification.
A “Conflict of Interest” shall be defined as any situation or circumstance where, in relation to this Competition process, the Applicant has an unfair advantage or engages in conduct, directly or indirectly, that may give it an unfair advantage, including (i) possessing or having access to information in the preparation of its Proposal that is confidential to Island Health and is not available to other Applicants; (ii) communicating with any official or representative of Island Health or members of the Evaluation Committee with a view to influencing them and obtaining preferred treatment in this Competition process; or (iii) engaging in conduct that compromises or could be seen to compromise the integrity of the open and competitive Competition process.
2. Conflict of Interest Declaration
I, (Name of the Applicant), have carefully reviewed my own situation and/or that of the institution which I represent and declare as follows:
___ I have no conflict of interest to declare,
___ I am involved in some situations or actions that might be regarded as a potential Conflict of Interest. Details of each of these situations and/or actions are as follows:
I agree to notify Island Health immediately if any situations or actions develop that might be regarded as a potential Conflict of Interest in respect of this Competition process. I hereby declare of the contents of this Statement of Full Disclosure and Conflict Of Interest Declaration to be true and correct.
Signature: ______ Dated this _ day of , 2015
Name of Applicant (please print):