Submission of this form serves as your electronic signature.

Note: All "yes" answers require additional information.

1. During the past 12 months, did you receive salary or consulting compensation or other forms of payment from an outside, non-Brown affiliated entity exceeding $5,000? Payments you received prior to your date of hire as a Brown employee do not need to be reported.
   
   Brown University’s Conflict of Interest and Commitment Policy defines reportable financial interest as:
   • Receipt of anything of monetary value from a single source exceeding $5,000 annually, such as salary, royalties, and payments for services (including consulting fees and honoraria). It does not include inheritances, income from debt obligations of the U.S., state, or local governments, certificates of deposit, blind trusts, and broadly diversified mutual funds and brokerage accounts managed by third parties.
   • Ownership of an equity interest exceeding the lesser of 5% or $100,000 in any single entity, excluding U.S., state, or local government debt obligations, certificates of deposit, blind trusts, and broadly diversified mutual funds and brokerage accounts managed by third parties.
2. During the past 12 months, did you have a reportable financial interest in an entity that you know does business, indirectly or directly, with Brown?
3. During the past 12 months, did you invest personally or own stock in a privately held business venture of a subordinate or student or trainee under your direct supervision or mentorship?
   
   Brown University’s Conflict of Interest and Commitment Policy defines family member as:
   • Spouse or domestic partner
   • Parent, stepparent, or parent-in-law
   • Child, stepchild, child-in-law
   • Sibling, stepsibling, or sibling-in-law
   • Grandparent or step-grandparent
   • Grandchild or step-grandchild
   • Guardian, ward, or other members of one’s household
4. Do you currently have a family member who is employed by the University, is a consultant or independent contractor doing business with the University, or is a student at the university?
5. During the last 12 months did you, or do you currently have a family member who has or is doing business with a Brown University employee who you directly or indirectly supervise?
   
   If yes, provide the name of the family member, their business, their relationship to you, and the Brown employee's name.
   
   Brown University’s Conflict of Interest and Commitment Policy defines associate as any individual or organization with whom you have a close personal or business relationship.
6. Have you been in the past, or are you now able, to exercise control or influence over a business relationship between Brown and an associate?
7. Brown University’s Non-Fraternization Policy prohibits emotional (romantic) or physical (sexual) intimate relationships where there is supervision, direction, or control between the parties at Brown. However, should such a relationship arise, the policy requires prompt reporting so that the University can eliminate or mitigate known risks as a result of the relationship. Are you involved in any such reportable relationship?
8. Do you serve in any uncompensated or minimally compensated position of responsibility, such as Officer, Director, or member of the Board of Directors, at a non-Brown entity or organization?
9. Do you hold or do you intend to seek election or appointment to a public office?
   
   In order to avoid a conflict of interest or the appearance of a conflict of interest, members of the Brown community are prohibited from accepting personal gifts and favors from a donor; current, prospective, or former student or parent; or others with whom there is a potential or existing business or professional relationship, in most circumstances as noted below:
   • Personal gifts valued in excess of $100 or of undetermined value are prohibited and must be returned immediately.
   • Personal gifts valued up to and including $100 may be accepted, but if accepted, must be reported to your supervisor when received, and during the annual Conflict of Interest and Commitment process.
   • The following are excluded from mandatory disclosure:
   • Payment for a modest meal
   • Copies of professional materials
   • Modest gift basket(s) or nominal food item(s) shared widely with colleagues
   • Promotional item(s) of nominal value routinely distributed by vendors to clients
   • Personal gifts received outside of your relationship with the University, such as birthday gifts between relatives.
10. During the past 12 months, did you receive a personal gift or favor from a donor; current, prospective, or former student, or parent thereof; or other individual(s) with whom there is a potential or existing business or professional relationship?
11. Do you currently use or intend to use University facilities, personnel or Brown students, or Brown’s name or likeness, for the benefit of any outside interest or activity or a non-Brown entity?
12. The previous questions ask you to describe your affiliations and activities.  Are there other conflicts of interest or commitment that you have as a result of these or other interests, activities, or relationships?