CONFLICTS OF INTEREST (COI) DECLARATION

Declarant's Details
Employee ID/Serial #: 
Full Name: 
Substantive Role Title: 
Are you a Senior Executive (including TAA)?: 
Contact Number: 
Division: 
Employment Status: 

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  I declare the following:-
  I hereby declare the details provided are correct to the best of my knowledge and I make this COI declaration in good faith.  
  I understand that if the circumstances as set out in this declaration change, I am required to resubmit a new declaration setting out the circumstances for approval.  
  I acknowledge that this conflict of interest declaration expires on 30 November each year.  
  I acknowledge that I have discussed this declaration with my supervisor/delegated officer and agreed upon the proposed action(s) and strategy for managing this COI.  
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  I understand that personal information collected, managed and disclosed on this form will comply with the requirements of the NSW Privacy Laws as outlined in the Department’s Privacy Management Plan.  
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Supervisor's Details
Supervisor's Name: 
Supervisor's Role Title: 
Supervisor's Email Address:   
Supervisor's Contact Number: 

Conflict details
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Date conflict of interest identified:
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Type of conflict: 

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What does the conflict of interest relate to?: 








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Describe the conflict: 

Proposed management Plan by the Declarant
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Proposed management plan negotiated with my Supervisor:
  Implement closer supervision
  Take no further action but continue to monitor
  Limit declarant’s involvement in process(es) including segregating or reducing duties
  Confine declarant to advisory role with no decision-making authority or financial delegations
  Prevent declarant’s dealings with external parties
  Limit access to systems, information or assets
  Prohibit Secondary Employment or Unpaid Work
  Provide an undertaking to refrain from communicating with particular parties during a process
  Add an independent third party to oversee part or all of a process
  Engage a subject matter expert to review the work of the declarant
  Engage a colleague of equal or greater seniority (to the declarant) to be involved in the matter
  Remove the declarant from the relevant task or assignment
  Exclude declarant from certain discussions or meetings
  Exclude declarant from critical recordkeeping functions
  Transfer matter to a different team to remove the conflict from the declarant
  Transfer the declarant to another project, branch or unit
  Remove declarant’s access to electronic or physical records
  Obtain agreement to relinquish ownership or control of a financial interest e.g. shares, land or controlling interests in a business etc.
  Declarant to resign from DCJ as the conflict cannot be otherwise managed
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Specific details of management strategy: 

Additional document (optional)
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