Disclosure Form

Policy of Ethical Practice

Name:
Department:
Contact Telephone Number:
Date Submitted:

Employee Disclosure: (Please provide as much information as possible to make an informed decision. Use additional page if necessary.)

Please indicate if this activity will be one-time or on-going:

One – Time	On – Going (Disclosure will remain in place for 3 years)

I certify that the information listed above is complete and accurate. I also acknowledge that I have discussed the information above with my supervisor and others as necessary, prior to submission for approval.

EMPLOYEE SIGNATURE:	DATE:

IMMEDIATE SUPERVISOR SIGNATURE:	DATE:

(Dean’s signature required for faculty disclosures)

University Leader Approval:

Employee disclosures must be reviewed (approved / denied) by the appropriate University leader as outlined below:

Provost and Vice President for Academic Affairs – Academic Affairs

Vice President for Business Affairs – Business Affairs

Vice President for Corporate Relations & Strategic Initiatives – Corporate Relations and Strategic Initiatives

Vice President of People and Culture – Human Resources

President – All Others

APPROVED	DENIED	SIGNATURE:	DATE:

Completed forms should be returned to humanresources@rmu.edu

Officer & Key Employee Disclosure:

Please note that Officers and those employees identified as Key Employees (as outlined in section six of the Policy of Ethical Practice) should use the Officer and Key Employee Conflict of Interest Disclosure Form. Please contact the Controller if you have been identified as an officer or key employee and you have a disclosure to submit outside of the normal annual officer and key employee disclosure process.