UVI Conflict of Interest Disclosure (COI) Determination Form 
First Name: 
 
Last 
Name: 
 
Department: 
 
Position 
Title: 
 
Please use this Form to determine if you need to complete and submit Appendix A:  Annual Financial 
Interest Disclosure Form and/or Appendix C: Outside Employment, Consulting, or Contracting 
Disclosure Form. 
 
Instructions 
If your responses to Questions 1 and 2, below, are No, please sign this Disclosure Determination Form 
and return it to your supervisor/manager. 
 
If your response to Question 1 and/or Question 2 is Yes, please complete the appropriate Form(s) and 
attach the Form(s) to this Disclosure Determination Form and submit this information to your 
supervisor/manager. 
 
Questions 
If you have any questions regarding the COI Disclosure Determination Form, Appendix A:  Annual 
Financial Interest Disclosure Form, or Appendix C:  Outside Employment, Consulting, or Contracting 
Disclosure Form, please contact the Human Resources Office at 693-1410. 
1. Are you responsible for the design, conduct, or reporting involving federally-sponsored research, 
or are you authorized to enter into financial transactions on behalf of the University and in a 
position to influence these transactions? 
______ No 
______ Yes 
 If you responded Yes to Question 1, you must complete and attach Appendix A:  
Annual Financial Interest Disclosure Form.   
2. Are you currently or do you intend to engage in non-UVI employment, consulting, or contracting? 
______ No 
______ Yes  
If you responded yes to Question 2, you must complete and attach Appendix C:  
Outside Employment, Consulting, or Contracting Disclosure Form. 
I acknowledge that I have read and understand the University’s Conflict of Interest Policy and I 
certify that I either have no conflicts of interest to disclose or that I have completed and 
attached the appropriate Form(s) for a Conflict of Interest determination to be made by my 
supervisor/manager and Human Resources. 
Signature:  ____________________________________ 
 
 
Date: _______________________ 
 
 
 
SIGN