Conflict of Interest Declaration Form

External Referee – Conflict of Interest and Confidentiality Declaration

This form must be completed by all external referees and approved by the Faculty Dean/University Librarian at Carleton University before any promotion dossier is released for review.

Section A

External Referee:

Referee's Name:(Required)

Referee's Institution:(Required)

Referee's Country:(Required)

Referee's Academic Rank (ie, Associate, Full):(Required)

For the Promotion Consideration of:

Candidate's Name:(Required)

To the Rank of:(Required)

In the Faculty of:(Required)

Academic Unit(Required)

Section B

Thank you for agreeing to serve as an external referee. Kindly complete this form as appropriate, so that the Faculty Dean/University Librarian at Carleton University can consider any real, potential, or perceived conflicts of interest, and make any necessary recommendations.

DECLARATION

I have co-published with the applicant in the last six years.(Required)

Yes

I have worked on a research grant or contract with the applicant in the last six years.(Required)

Yes

I have supervised the applicant as a PhD student.(Required)

Yes

I have acted as a research supervisor to the applicant in another capacity.(Required)

Yes

I have been supervised by the applicant.(Required)

Yes

I have common business interests with the applicant, or have had common business interests in the last six years.(Required)

Yes

I have plans to collaborate with the applicant in the next six months.(Required)

Yes

I have other conflicts of interests (personal, financial, etc) with the applicant.(Required)

Yes

If you answered "Yes" to any of the statements above, please describe the real, perceived, or potential conflict of interest.

Submitter email address

Confidentiality Acknowledgement & Undertaking

I understand that the integrity of the University and the review process depends on my participation in the review process being conducted in an impartial, ethical, confidential, and respectful manner. I hereby agree to:

Respect and maintain the absolute confidentiality of all applicants for tenure and/or promotion. I will not reveal the name(s), or any information about such persons at any time;

Keep confidential all documents and information, whether in the form of papers, books, files, documents, electronic communications, or in any other form or format including oral communications, which comes into my possession or knowledge in my capacity as a committee member and relates to the promotion of the applicant;

Keep any downloaded documents secure and password-protected and not publicly accessible;

Not divulge, disclose, or communicate, in any form or manner, directly or indirectly, such confidential information to any person, firm, corporation, or other entity, other than a person otherwise designated by the University, to receive such confidential information;

Ensure that all materials in my possession are shredded and/or digitally destroyed, as applicable at the end of the review process.

Updated: August 16, 2016

Do you agree to the above Confidentiality Acknowledgement & Undertaking statement?(Required)

I Agree

Privacy Statement

The personal information requested on this form is collected in accordance with Sections 38(2) and 41(1) of the Freedom of Information and Protection of Privacy Act (FIPPA), R.S.O. 1990, c.F.31 as amended. The information provided will not be used for any purposes other than those stated upon this form. Should you have any questions concerning your personal information, please contact the Dean’s Office. Carleton University is fully compliant with FIPPA and endeavours at all times to treat your personal information in accordance with this law.

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