KANSAS STATE UNIVERSITY

ANNUAL DECLARATION AND DISCLOSURE
Disclosure Policy and Procedures

In order to comply with federal regulations and Board of Regents (BOR) policy, Kansas State University (KSU) requires all unclassified faculty and staff with 100% time appointments to annually file Annual Declaration and Disclosure. Faculty and unclassified staff members who hold fractional appointments who have potential or possible conflicts of time or conflicts or interest are also required to file disclosure forms. Please refer to the policy on Conflict of Interest and Conflict of Time Commitment. The disclosure forms assess any real or potential conflicts of time or financial interest that are related to faculty research and other university activities. If you answer "NO" to all questions on Section A, then simply sign and return Form A. If you answer "YES" to any question on Form A (with the exception of Section B.1) then complete the appropriate sections of the Disclosure Form B, sign and return both forms.

Kansas State University recognizes the value of faculty and staff interaction with business and industry, private foundations, and government agencies to foster the University mission, facilitate professional development, and promote expansion of knowledge. In some cases the external activities of faculty and staff, such as consulting, outside employment, public service, pro bono work, or serving as an officer of an external entity, even without compensation, can result in real or apparent conflicts regarding commitment of time. BOR policy states that full-time unclassified faculty and staff of K-State owe their primary professional responsibility to their employing institutions and their primary commitment of time and intellectual effort should be to the education, service, research, and scholarship missions of the University. Faculty and unclassified staff should maintain a presence on campus commensurate with their appointments. External professional activities that take time away from University responsibilities should be discussed with the department chair or other immediate supervisor to obtain concurrence that the activities do not constitute a conflict of time commitment. A Consulting Request  should be completed and approved prior to engaging in external professional activities. Disclosure of relevant significant financial interest is required of all full-time faculty and unclassified staff and all other University employees who have potential or possible conflicts of interest or time commitment. Failure to comply with the policy may result in disciplinary action. Also, individuals will not be allowed to submit internal or external grant applications without compliance.

Definitions
Conflict of Interest: A potential conflict of interest occurs when there is a divergence between private interests and professional obligations to the University such that an independent observer might reasonably question whether the professional actions or decisions are determined by personal financial gain.

Conflict of Time Commitment: A potential conflict of time commitment exists when professional activities external to the University exceed reasonable time limits or whenever primary professional responsibility is not to the University.

Covered Individuals: Kansas State University policy covers all full-time unclassified faculty and staff and all others who have potential or possible conflicts of interest or time commitments.

Family: Family includes spouse, dependent children, and members of personal household.

 

CONFIDENTIAL
Form A    Declaration for Conflict of Interest and Time Commitment

A. Employee Identification

Name:
Dept/Unit:
Title:

SECTION A - CONFLICT OF INTEREST
  1. Ownership: Ownership interest in any corporation, partnership, trust, joint venture, and every other business interest, including land used for income which you or other members of your household own or have owned within the preceding 12 months, which represents a legal or equitable interest exceeding $10,000 or five percent, whichever is less. Ownership of intellectual property, e.g., patents, royalties, and copyrights is also included. Ownership of funds and holdings acquired through the Regents' retirement programs is not included.

    Are there any ownership interests you have or a member of your family has which meet this criteria and could an independent observer conclude that they appear to influence or potentially conflict with any of your research/educational activities?
         No     Yes (If yes, complete sections A, B, C, G, and H on Form B)

  2. Compensation: Receipt of salary, anything of value, or economic benefit conferred within the past 12 months in return for services rendered or to be rendered in excess of $10,000, including consulting fees in excess of $10,000 from any one entity.

    Have you or your family received or do you expect to receive compensation as defined above and could an independent observer conclude that said compensation influences or potentially conflicts with any of your research/educational activities?
         No     Yes (If yes, complete sections A, B, D, and H on Form B)

  3. Office: A position or office of director, officer, associate, partner, or proprietor in any outside entity in which greater than 5% ownership is held or for which more than $10,000 compensation is received.

    Do you or does a member of your family hold an office as defined above which an independent observer could conclude significantly affects or is affected by any of your research/educational activities?
         No     Yes (If yes, complete sections A, B, E, and H on Form B)

  4. Fees and Commissions: Receipt of an aggregate of $10,000 or more in fees or commissions from one or more outside entities.

    Do you or does a member of your family receive fees/commissions as defined above which meet this criteria which an independent observer could conclude might present potential conflicts of interest with any of your research/educational activities?
         No     Yes (If yes, complete sections A, B, F, and H on Form B)

  5. Single 24-hour Activities:  For faculty members only, personal, professional activities that occur within a single 24-hour period need not have prior approval but must be reported annually in writing on this form.

    Did you engage in any such single-occasion activities which were not previously reported and approved?

         No     Yes (If yes, please complete a Consulting Request form for each activity and attach hereto)  

If you have answered "Yes" to any of these questions, indicating that to an independent observer a specific financial interest has the potential of affecting or influencing your research/educational activities, you are required to file a Disclosure Statement Form B identifying the specific interests and the affected research/educational activities (see attached Disclosure Statement Form B).

 

SECTION B - CONFLICT OF TIME COMMITMENT
The Board of Regents recognizes the value of faculty and staff interaction with business, industry and private foundations and government agencies to foster the missions, facilitate professional development, and promote expansion of knowledge.

However, the Board of Regents' policy indicates that external activities of faculty and staff, such as consulting, outside employment, public service, pro bono work, or serving as an officer of an external entity, even without compensation, can result in real or apparent conflicts regarding commitment of time or effort.

The policy states that faculty members and unclassified staff of Regents' institutions owe their primary professional responsibility to their employment institutions, and their primary commitment of time and intellectual effort should be to the education, service, research and scholarship missions of said institution. Faculty and unclassified staff should maintain a presence on campus commensurate with their appointments.

External activities that take time away from University responsibilities should be discussed with the department chair or other immediate supervisor to obtain their concurrence that the activities do not constitute a conflict of time commitment. This concurrence should be obtained prior to engaging in external activities.
  1. I have read and I understand the Regents' policy on Commitment of Time, Conflict of Interest, Consulting and Other Employment. BOR policy can be accessed at http://www.kansasregents.org/download/aca_affairs/policymanual/kborpm71002.pdf
         No     Yes

  2. In light of Regents' policy, some of my external activities may appear to an independent reasonable observer to create a conflict of time or effort.
         No     Yes (If yes, complete sections A, G, and H on Form B)

 

DECLARATION:
I, __________________________________, declare that this report of financial interest and potential conflict of interest has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement. I have read the Regents' Commitment of Time, Conflict of Interest, Consulting and Other Employment Policies and I have complied with consulting approval policies and procedures of K-State. I have complied with federal conflict of interest policies and regulations. Also, I understand that Regents' policy states that failure to file this statement as required or intentionally filing a false statement may result in disciplinary action. Any changes to this statement will be reported prior to proposal submission.

________________________________________
Signature		 _______________________
Date		 _______________________
Employee ID #

If all answers are "No" except for B.1 you do not need to complete Form B.


ACCEPTED: ______________________________
Department/Unit Head		 _______________________
Date
ACCEPTED: ______________________________
Dean/Appropriate Vice President		 _______________________
Date
ACCEPTED: ______________________________
Provost		 _______________________
Date

 

(ONLY TO BE COMPLETED IF REQUIRED BY ANSWERS TO Form A) CONFIDENTIAL

Form B    Disclosure Statement of Significant Financial and/or Time Commitment Interests

A. EMPLOYEE IDENTIFICATION
Name:
Dept/Unit:
Title:

SECTION 1 - CONFLICT OF INTEREST
In compliance with Federal, Board of Regents, and Kansas State University policies, disclosure of relevant significant financial interest is required of all full-time faculty and unclassified staff and all other members of the University community who are responsible for the design, conduct, or reporting of research or educational activities. The disclosure of interests includes those of the University employee, his or her spouse, dependent children, and other members of the personal household.

"Significant Financial Interest" means anything of monetary value including, but not limited to, salary or other payments for services (e.g., consulting fees or honoraria), equity interests (e.g., stocks, stock options, or other ownership interests), and intellectual property rights (e.g., patents, copyrights, and royalties from such rights). The term does not include any of the following:
  1. Salary, royalties, or other remuneration from the University, including funds and holdings acquired through the Regents' retirement programs;
     
  2. Income (e.g., salary, fees, or other continuing payments) in an amount of $10,000 or less per annum from any one business enterprise or entity when aggregated for the employee and members of his/her family.
     
  3. Financial interest in any one business enterprise or entity if the value of those interests does not exceed a five percent ownership interest when aggregated for the employee and members of his/her family.
B. IDENTIFICATION OF POSSIBLE CONFLICT

Identify the relevant research and education activities that may be affected by the financial or ownership interest that you, your spouse, dependent children, or other members of your personal household may have. Complete the remainder of this section with this possible conflict in mind. If more space is needed, please add an additional page.

 

C. OWNERSHIP INTERESTS
List any corporation, partnership, proprietorship, trust, joint venture, and every other business interest, including land used for income in which either you or other members of your household own or have owned within the preceding 12 months a legal or equitable interest exceeding $10,000 or five percent, whichever is less, which influences or potentially conflicts with any of your research/educational activities. If you or members of your household own more than five percent of a business, you must disclose the percentage held. Please insert additional pages if necessary to complete this section.

If you have nothing to report in Section "C", check here
Business Name and Address Type of Business Description of Interest Held Held by Whom Percent of Ownership Interests
You
Spouse
Other*		 You
Spouse
Other*
You
Spouse
Other*		 You
Spouse
Other*
You
Spouse
Other*		 You
Spouse
Other*
* "Other" refers to dependent children and other members of your household.
D. RECEIPT OF COMPENSATION
List all places of employment and other business from which you or any member of your household expect to receive $10,000 or more in compensation which to an independent observer could influence or potentially conflict with any of your research/educational activities.

D.1 YOUR place(s) of employment or other business in the preceding calendar year.
If same as section "A" (current employment), check here
If you have nothing to report in Section "D.1", check here
Name of Business Address Type of Business
D.2 SPOUSE'S place(s) of employment or other business in the preceding calendar year.
If you have nothing to report in Section "D.2", check here
Name of Business Address Type of Business

 

D.3 OTHER HOUSEHOLD MEMBER(S) place(s) of employment or other business in the preceding calendar year.
If you have nothing to report in Section "D.3", check here
Name of Business Address Type of Business
E. OFFICER OR DIRECTOR OF AN ORGANIZATION OR BUSINESS
List any organization or business in which you, your spouse, or any other member of
your household, hold a position of officer, director, associate, partner, or proprietor for which more than an aggregate of $10,000 compensation is received per year or more than five percent is owned which significantly affects or will be affected by any of your research/educational activities. Please insert additional pages if necessary to complete this section.

If you have nothing to report in Section "E", check here
Name and Address of Business Position Held Held by Whom
F. RECEIPT OF FEES AND COMMISSIONS
List each client or customer from which you, your spouse, or any household member receives an aggregate of $10,000 or more per year which could present a potential conflict of interest with any of your research/educational activities. In the case of partnership, it is your proportionate share of the business or fee that is significant, without regard to expenses of the partnership. An individual who receives a salary as opposed to portions of fees or commissions is generally not required to report under this provision, but may be required to report under Section D above. Please insert additional pages if necessary to complete this section.

If you have nothing to report in Section "F", check here
Name and Address of Client or Customer Position Held Held by Whom

 

SECTION II. CONFLICT OF TIME OR EFFORT

G. IDENTIFICATION
List external activities such as consulting, external employment, public service, holding of office or pro bono work, even if not compensated, that represent significant time commitment efforts which may be or appear to be a conflict of time commitment situation.

An example would be serving as national president of the Boy Scouts of America which requires your out-of-state presence three days a week. Another example might be that you are an unpaid consultant to a private entity at a significant level of effort.
External Entity Projected level of effort per year Purpose
H. DECLARATION
I, ______________________, declare that this statement of significant financial interest and time commitments (including accompanying pages and statements) has been examined by me and to the best of my knowledge and belief is a true, correct and complete statement of all my significant interests and other matters required by law. I have read and agree to abide by federal and Regents' conflict of interest policies and K-State policies and procedures. Also, I understand that Regents' policy states that failure to file this statement as required or intentionally filing a false statement may result in disciplinary action. Any changes to this statement will be reported when the information becomes known to me.

________________________________
Signature		 __________________
Date


Number of Additional Pages ____________

Return this form to your Department Head.

 

VERIFICATIONS
I have reviewed the (potential) conflicts of interest and/or conflicts of time commitment with the above named individual, and procedures have been implemented to manage the (potential) conflicts. As implemented, these management practices should ensure that none of the above referenced conflicts or potential conflicts will interfere with the performance of the individual's teaching, research, and/or professional service activities.

There is no conflict

A potential conflict exists and a plan has been developed to manage it, which is attached and consists of ____ pages.

________________________________
Department/Division Head		 __________________
Date
________________________________
Dean/Appropriate Vice President		 __________________
Date
________________________________
Provost		 __________________
Date