CONFLICTS OF INTEREST (COI) DECLARATION

Declarant's Details Employee ID/Serial #:  Full Name:  Email Address:  Substantive Role Title:  Are you a Senior Executive (including TAA)?:  YesNo Contact Number:  Entity:  [Select one] Advocate for Children and Young People (ACYP) NSW Trustee and Guardian (TAG) Department of Communities & Justice (DCJ) Multicultural NSW (MNSW) Ageing and Disability Commission (ADC) Division:  Select entity above... District/Directorate:  Branch (optional):  Employment Status:  [Select one] Public Service Employee (ongoing, temporary/termed) Non Public Service Employee (i.e. Contractors, Contingent Workforce etc.)

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.     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.

Supervisor's Details Supervisor's Name:  Supervisor's Role Title:  Supervisor's Email Address:   You cannot select yourself Supervisor's Contact Number:

Conflict details Date conflict of interest identified: Type of conflict:  An actual, existing conflict of interest Something that has the potential to become a conflict of interest Something that could be perceived by others as a conflict of interest What does the conflict of interest relate to?:  Shareholdings Trust/Nominee Companies A position you hold in a company (including subsidiaries) e.g. directorship, partnership, liquidator, administrator, secretary etc. Business interests you hold such as sole proprietor, partnership etc. Relatives or close associates Investment properties you or any of your close associates hold an interest in Paid employment within the cluster that is in addition to your substantive role in DCJ Paid employment outside your role in DCJ and the cluster Voluntary work such as unpaid membership of boards, committees community groups etc. Other (please specify) Describe the conflict

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