THE CENTER FOR FAMILY SUPPORT, INC

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Policy and Procedure: Corporate Compliance Topic: Code of Conduct & Conflict of Interest SCOPE OF POLICY This policy applies to all Center for Family Support (CFS) employees, including trainees, volunteers, consultants, contractors or subcontractors as well as The Board of Directors.

STATEMENT OF POLICY The Center for Family Support, Inc. (CFS) serves as a role model for the community and aspires to provide its services in accordance with the highest ethical standards possible. CFS is committed to conducting its business ethically and in conformance with all federal and state laws, regulations, interpretations thereof, and this Code of Conduct & Conflict of Interest policy. To support this commitment, CFS will maintain and update as appropriate this written Code of Conduct & Conflict of Interest Policy to provide employees, Board members, and agents with guidance on requirements for conduct related to employment or engagement as well as organizational responsibilities related to compliance. All employees, Board members and agents will be provided a copy of the Code of Conduct & Conflict of Interest policy and participate in training sessions on an annual basis that include a thorough review of the document. In accordance with this goal, employees are required to abide by ethical and legal standards and to uphold the agency's integrity and reputation. This includes all statutes enforced by the local, state or federal government. This Code of Conduct & Conflict of Interest Policy addresses specific issues related to reimbursement, financial relationships, quality of care, and other critical areas and describes important aspects of the agency compliance program including, but not limited to the problem resolution process, Corporate Compliance/Whistleblower hotline, and non-retaliation policy. This policy has also been established to ensure that services and business activities are conducted in an objective manner and are not motivated by desire for personal or financial gain. It is the intent of this policy to convey an understanding of the expectations of CFS and provide written guidelines for employees regarding ethical conduct, honesty, and appropriate behavior, both during business and non-business hours. For the purpose of this policy, the following definition of conflict of interest will be used:

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Conflict of Interest: Any situation in which financial or other personal considerations may compromise or appear to compromise (1) an employee or Board Member’s business judgment; (2) delivery of services; or (3) ability for an employee to do his or her job. An actual or potential conflict of interest occurs when an employee is in a position to influence a decision that may result in a personal gain for that employee or for a relative or a significant other as a result of business dealings. For the purpose of this policy, a relative is any person who is related by blood or marriage, or whose relationship with the employee is similar to that of persons who are related by blood or marriage. 1. All employees and Board Members are required to disclose any actual or potential conflict of interest and seek guidance on how to handle the situation. Business dealings with outside entities should not result in unusual gain for those entities, CFS, CFS Board Member or any CFS employee. Unusual gain refers to bribes, product bonuses, special fringe benefits, unusual price breaks, and other windfalls designed to ultimately benefit the employer, the employee, or both. 2. The materials, products, designs, plans, ideas, and data recorded and/or developed by any CFS personnel are the property of CFS and should never be given to an outside entity or individual except through normal channels with appropriate prior authorization. Any improper transfer of material or disclosure of information, even though it is not apparent that an employee has personally gained by such action, is prohibited. 3. Every employee is prohibited from partaking in any activity or association that creates or appears to create a conflict between the employee's personal interests and the agency's business interests. In addition, an employee must not allow situations or personal interests to interfere with the exercise of independent judgment or with that employee's ability to act in the best interest of the agency. Employees who are unsure of whether there exists a conflict or the appearance of a conflict should seek the counsel of the Executive Director or the Director of Human Resources. 4. Investments: Employees are prohibited from investing in any of the agency's suppliers or competitors unless the securities are publicly traded and the investments are on the same terms available to the general public and not based on any "'inside information”. This prohibition applies to all forms of investments and to all employees of the agency and their immediate families. 5. Gifts, Gratuities and Entertainment: (Also refer to the separate policy on gifts and entertainment): Employees may not give or solicit any money, gratuities, gifts, favors or any other personal benefits to or from any consumer, family or friend of a consumer, supplier, or competitor. Employees are not permitted to give or receive a gift in the form of cash, travel expenses, personal services, stocks, bonds, options, or similar types of items. Employees must not offer or

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accept entertainment that is not a reasonable addition, but is primarily intended to gain favor or to influence a business decision. It is impermissible and may be unlawful to give, offer, or promise anything of value for the purpose of influencing someone in connection with agency business or an agency transaction. Similarly, it is impermissible and may be unlawful to solicit, demand, or accept anything of value with the intent of being influenced or rewarded in connection with any agency business or transaction. Therefore, no employee may give or receive any gift reasonably viewed as being done to gain an advantage. Employees are not prevented from incurring normal business related expenses, with approval obtained in advance, for meals or entertainment or from accepting personal mementos of minimal value. It is not acceptable to allow a consumer or family or friend of a consumer, to pay for a business meal or entertainment. While it is not encouraged, it is permissible for an employee to accept an invitation to a business meal or social event from a supplier or vendor to further develop a business relationship. As a general rule, the costs associated with such events should not exceed $100.00. Business / social events with vendors or suppliers that involve overnight accommodations, expenses or costs above $100.00 should be discussed with the employee’s supervisor and the CFS Executive Director. 6. Outside Employment: No employee may serve as an employee, director, or officer of any supplier or vendor. Any employee who does perform outside work has a responsibility to avoid and prevent any conflict with the agency's business interests. Outside work cannot be performed on CFS work time nor can it interfere with an employee's CFS responsibilities, including the requirement to work overtime or to handle an emergency. A conflict will arise when CFS and its employees are competing as individuals or as employees of outside employers to provide as many of the necessary services as possible to a consumer to ensure a holistic and qualitative approach to care. When such conflicts arise, the employee is not permitted to advocate for provision of such services by providers other than CFS when CFS is a provider of the services in question. Such conduct is inconsistent with CFS’ qualitative approach to service provision and could be detrimental to consumer care and well-being. Instances of this type of conduct include, but are not limited to: a) when the employee may reap a monetary benefit from this arrangement, b) when such an arrangement would cause CFS to be denied the opportunity to provide any particular service to the particular consumer, c) when a consumer is removed from CFS services,

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d) or when the consumer will receive fewer services from CFS as a result. 7. Family Relationships: The Center for Family Support will not be inappropriately influenced with goods or services from any business in which any employee or immediate family member has a substantial interest. If an employee wishes to do business on behalf of the agency with a member of that employee's immediate family, other relative, domestic partner, or common law spouse, or with a company of which a member of the employee's immediate family, other relative, domestic partner, or common law spouse is an officer, director, principal, or employee, the employee must first disclose the relationship and obtain the prior written approval of the Executive Director. Under no circumstances will CFS favor or show special consideration to any employee’s relatives or friends or hire such persons to the detriment of the agency. A. Nepotism: It is the policy of The Center for Family Support to ensure a fair and open competitive selection process in the employment of personnel. This policy is created to address and alleviate management problems as well as conflicts of interest that the agency perceives to potentially exist when family members or strong family friends are working in the same department. The hiring of immediate family members or strong family friend is not permissible if:  There is a direct reporting relationship or 

The immediate family member or friend will be working in the same program area and/or in the same work site or

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The immediate family member or friend will occupy positions in the same “decision making” process which would compromise internal controls (i.e. decisions regarding approval of contract, payment of fees, acceptance of proposals)

The following employment selection guidelines are followed:  No one involved in the selection process shall be an immediate family member or friend of a prospective candidate. 

An applicant will not be selected if there is a reporting relationship to an immediate family member or friend.

8. Confidential Information: All employees, consultants, independent contractors and volunteers have an ethical duty not to disclose any proprietary and/or confidential information, as stipulated by current state and federal laws, including the mental hygiene laws on confidentiality and HIPAA guidelines, gleaned from agency transactions to unauthorized parties, and to protect confidential relationships between the agency and its consumers, suppliers, vendors, and employees. The HIPAA minimum necessary rule and disclosures

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made only for purposes of treatment, payment for services and other routine business operations apply in all instances when protected health information is in question. This obligation continues after the termination of employment or after the discontinuance of the utilization of the individual's services by the agency. Business information that has not been made public shall not be released without prior approval to private individuals, organizations, or government bodies unless demanded by legal process such as a subpoena or court order or pursuant to governmental regulations. Employees, consultants, independent contractors and/or volunteers shall not use confidential information obtained in the course of their service with the agency for the purpose of advancing any private interest or otherwise for personal gain. Requests for information (reference checks, criminal background checks, credit reporting, etc.) about a present or a former employee of the agency must be referred to the Human Resources Department for handling. 9. Agency Funds, Services, Equipment: Employees should not use, directly or indirectly, any agency funds, assets, services, or equipment (including, but not limited to vehicles, telephones (land lines and cellular telephones), copiers, scanners, fax machines, typewriters, electronic mail and computer equipment) for any purpose other than approved agency business, during business hours except for de minus use. For example, employees may make an occasional copy or fax or make or take short personal calls necessary to communicate with children, a babysitter, family, school etc. Calls should be brief and should not be outside of the metropolitan area. Employees may not use agency bulletin boards, other communication channels or access to the Internet at work to post, store, transmit, download or distribute any ethnic slurs, racial epithets, solicitations, threatening, sexually explicit or obscene materials including anything constituting or encouraging criminal activity, giving rise to civil liability, anything that may be construed as harassment or be offensive to others or otherwise violating any laws. Additionally, these channels of communication may not be used to send chain letters, personal broadcast messages, or copyrighted documents that are not authorized for reproduction, nor are they to be used to conduct business for an another employer, consulting work, a job search, solicit religious or political contacts or correspondence. 10. Purchase and Sale of Goods: As dictated by the Antitrust laws, employees are forbidden to conspire to fix prices or to monopolize. Employees will not practice reciprocity by awarding business to another organization because that organization is purchasing goods or services from CFS. Employees will not meet with other buyers from an organization to conspire to boycott a particular supplier of goods and services. As per tax laws, employees will utilize an agency tax exempt form when making purchases. The Center for Family Support, Inc. provides an agency credit card to managers and administrative staff designated by the CFS Executive Director to streamline the purchasing process by enabling management to expeditiously shop and pay

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for items needed to address consumer needs. Authorized uses of the credit card include, but are not limited to the following items:  Purchase of household items such as dishes, linens, over-the-counter medications, beauty products and toiletries that are needed quickly and can not await money obtained via the check request procedure or cost more than what is allotted in or remaining in the petty cash fund at that time. 

Replacement of items necessary to maintain healthy living standards such as beds, furniture, carpets, and window treatments.

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Consumer recreation such as tickets to an event and restaurants, with prior approval from the cardholder’s supervisor or Department Director.

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Training supplies.

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Conference or training seminars with approval from the cardholder’s supervisor or Department Director.

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Parking and fuel purchase are allowed when necessary.

Credit cards should not be utilized for any cash advance or for any personal use. The full policy regarding the process of providing credit cards to employees, the use and monitoring of credit card expenses is recorded in a separate policy maintained in the CFS Fiscal Operations Manual. The Center for Family Support has also established a petty cash account for all residential programs and day services programs to use to make purchases for consumers and staff. The petty cash account and amount is established for each program by the CFS Department Director in concert with the CFS Controller. The petty cash account operates under an imprest (a loan or advance of money) system. As custodians of petty cash accounts, the manager or supervisor of the respective program has a fiduciary (trustee) responsibility to safeguard the organization’s financial activity. Cash accounts, such as petty cash, undergo strict scrutiny by both regulatory agencies and independent audit firms. The full policy regarding the process of providing petty cash to employees, the use and monitoring of such expenses is recorded in a separate policy maintained in the CFS Fiscal Operations Manual. 11. Financial Reporting: All financial information must reflect actual transactions and conform to generally accepted accounting practices. The agency prohibits the establishment or maintenance of undisclosed or unrecorded funds or assets. All reporting of information should be accurate and timely. Employees may not make any false or misleading entries in any books and records.

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12. Travel and meal expenses shall be paid to an employee when such expense is incurred with the approval of a supervisor. Expenses that qualify for reimbursement are confined to those that are essential to the transaction of agency business. Ordinary travel between an employee’s home and work location are not reimbursable expenses. All expenses claimed shall reflect only amounts actually expended and should reflect reasonable modes of transportation. All expense reports shall be so itemized that the nature, purpose and necessity of each item is apparent. Corresponding receipts must accompany all expenses claimed. Refer to separate policy on Travel and Other Expense Reimbursement in this manual for further details. At the discretion of the CFS Executive Director, The Center for Family Support may provide an automobile to an employee to conduct CFS business, and also may allow personal use of the automobile. In such instance, the personal use of the automobile is a taxable benefit to the employee, and records are maintained to ensure that the appropriate value of the benefit is included on the employee’s annual W-2 form. The full policy regarding the process of providing an agency vehicle to employees, the use and monitoring of such related expenses is recorded in a separate policy maintained in the CFS Fiscal Operations Manual. 13. Marketing: CFS will not falsely advertise or market services that are not provided by CFS programs and CFS staff. All CFS documents and publications including brochures, newsletters, correspondence to families and government, agency website or any other communication used for marketing, fundraising or informational purposes will record accurate and current information about programs, consumers, service provision and the agency. 14. Political Contributions and Lobbying: Employees may enjoy membership and contribute to and/or lobby for political parties/candidates, trade associations and similar organizations. However, any political activity is strictly on the employee's own time and at the employee's own expense. 15. Employee Behavior: All employees are expected to behave in a professional manner. Employees should not use profanity or language that reflects any type of religious, ethnic, racial, gender, age or sexual bias. All forms of discrimination and harassment, including sexual harassment, are prohibited. Threats, threatening language or other acts of aggression or violence made by an employee will not be tolerated. Employees who report any forms of threats, harassment or discrimination will not be subject to any retaliation, intimidation or disciplinary action for doing so. All such reports or concerns will be thoroughly investigated by the Human Resources department. All matters pertaining to any such investigation will remain confidential. Proper business conduct includes conforming to generally high standards of courteousness, responsiveness and attention to acceptable business practices, which demonstrate the values of CFS as articulated in the CFS Mission Statement.

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This list is not meant to be exhaustive. There may be instances when employees find themselves in situations that may not be specifically addressed by this policy or are unsure as to whether an ethical concern may exist. In such an instance, employees are encouraged to discuss any concerns with the Human Resources Director who will, in turn, address the concern with the Executive Director. Any concerns regarding consumer care will also be discussed with the Director of Quality Assurance. Any instances of concern related to misuse, abuse or waste of Medicaid money will be shared with the agency Corporate Compliance Officer. The determination as to whether a conflict of interest exists will be decided ultimately by the Executive Director.

IMPLEMENTATION OF POLICY 1. The Corporate Compliance Officer (CCO) will maintain and periodically update The Center for Family Support’s Code of Conduct & Conflict of Interest policy. The Center for Family Support’s Board of Directors are responsible for oversight and final approval of the policy and any revisions. 2. The policy is written at a basic reading level, avoiding complex language and legal terminology in order to be understood by employees of all educational backgrounds. The policy addresses critical areas such as compliance with all related finance and corporate compliance laws and regulations, human resource practices, quality of care/service, conflicts of interest, proprietary rights, confidentiality of information as per current mental hygiene laws and HIPAA law, safety, and reimbursement practices. 3. The policy addresses specific areas of potential fraud, misuse, abuse or similar wrongdoing (e.g., claims development, submission processes, and diagnostic/procedural code selections) and addresses all stipulations, mandates and issues identified by the Federal Sentencing Guidelines, the Office of the Attorney General (AIG), the Office of Inspector General (OIG) and the Office of the Medicaid Inspector General (OMIG). 4. The policy also addresses Human Resources related compliance issues such as sexual harassment and discrimination, as well as CFS’s commitment to quality of care and service. 5. The Corporate Compliance Plan which includes the Code of Conduct and Conflict of Interest Policy as well as all other applicable policies are also provided to all Board members, executive personnel, managers, employees, independent contractors, and those with whom business is conducted. Copies will be provided to all new employees as part of the new employee orientation. All recipients of the document will sign and date a receipt that acknowledges: (a) receiving a copy, (b) attending a training on such, (c) reading and understanding the contents, and (d) agreeing to abide by the

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provisions of the document. A conflict of interest disclosure statement form will be completed by all Board members, executive personnel, managers, and all employees at time they commence work for/at CFS and minimally annually thereafter. These completed disclosure statements will be submitted to the Human Resources Department for review of any recorded conflicts of interest. Upon review and discussion with the applicable Program Director as needed, the Director of Human Resources will determine if any action is warranted to eliminate and/or reduce any conflict(s) of interest. The review and decisions made regarding the personnel in question will be recorded by human resources staff on the disclosure review form. 6. The Corporate Compliance Officer will ensure that all employees, Board members and agents receive training annually related to the contents of the policy to help them understand how it applies to everyday work situations and ensure that records are maintained to document the receipt of training. 7. The Corporate Compliance Officer will include in his or her report to the Agency Corporate Compliance Committee and Board of Directors the status of training, along with any recommendations for updating or improving the contents of the Code of Conduct and Conflict of Interest Policy. 8. All employees including all members of the senior management team and the Board of Directors will complete a Conflict of Interest Disclosure Statement at time of hire or commencement of service and annually thereafter. 9. All employees and Board members with questions and/or concerns about potential conflicts of interest will promptly address the issue with their respective supervisor who in turn will report such to the Corporate Compliance Officer, the Director of Human Resources or the Executive Director. 10. Employees must seek guidance and approval from executive personnel prior to pursuing any business or personal activity that may constitute or be perceived as a conflict of interest. 11. The Corporate Compliance Officer is responsible for investigations of possible violations of the Code of Conduct & Conflict of Interest policy and, in conjunction with the Human Resource Department, assuring appropriate remediation, preventative and corrective actions and disciplinary action as warranted has been taken when necessary. 12. The policy includes instructions to report fraud, abuse, suspected violations of the policy, or other suspected wrongdoing directly to the Corporate Compliance Officer, Director of Human Resources or the Executive Director of CFS. Written guidelines and contact information are provided on how employees and agents may report suspected violations of federal or state

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law, regulations, interpretations thereof, or the policy without fear of retribution or retaliation to the Corporate Compliance / Whistleblower Hotline or internetbased reporting system in place so that complaints may be registered in an anonymous fashion. 13. Written confidentiality and non-retaliation policies will be referenced and included as part of the Code of Conduct and Conflict of Interest policy for the purpose of encouraging communication and the reporting of incidents of suspected fraud or other wrongdoing.

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THE CENTER FOR FAMILY SUPPORT, INC. CONFLICTS OF INTEREST DISCLOSURE REVIEW (This review is completed upon receipt of a completed conflicts of interest disclosure statement that contains information about potential conflicts of an employment applicant or current employee, volunteer, vendor and/or Board member)

Name of Individual: _____________________________

Date of Review:__________________

1. Personnel from the human resources department who reviewed the completed disclosure statement: Name: Name:

Title: Title:

2. Personnel from the applicable department who reviewed and discussed the completed disclosure statement with the above named human resources staff: (done as a consultation as deemed necessary by Director of Human Resources): Name: Name:

Title: Title:

3. Current Employment Status: (one ):  Current Employee  Volunteer  Applicant _Temporarily Approved Provisional Employee  Vendor  Board Member 4. Name of Program / Site for this individual: a) Type of Program: b) Location of Program: 5. Position: (current or position applied for by this individual): 6. What is the potential conflict of interest / relationship? ______ __________________________________ ____________________________________ 7. Does or will this individual have a direct or indirect supervisory or subordinate position to the person with whom he/she has recorded a potential conflict of interest?  Yes (explain below)  No

8. For a new employment applicant, did the individual accurately record/disclose the potential conflict of interest/relationship on the job description?  Yes  No, explain below:

_________ 9. Describe steps taken, if any, to eliminate and/or reduce the potential conflict of interest: a) Has the referenced individual been relocated, reassigned or released from the agency?  Yes (explain below)  No b) Will the above referenced individual continue to work at the same location or in same capacity?  Yes (explain below)  No c) Will job duties or responsibilities be changed or limited?  Yes (explain below)  No d) Other; Explain Below:

Signature of Authorized Party: 1

CENTER FOR FAMILY SUPPORT, INC. Corporate Compliance Plan, Code of Conduct & Conflict of Interest Policy Acknowledgement Form

 I acknowledge that I have received, read, and that I understand The Center for Family Support’s Corporate Compliance Plan and Code of Conduct & Conflict of Interest Policy.  I understand that I must comply Support’s Corporate Compliance and Conflict of Interest Policy, policies, procedures, and other responsibilities of my position.

with The Plan, the and all guidance

Center for Family Code of Conduct laws, regulations, applicable to the

 I understand that my failure to report any concerns regarding possible violations of the law, regulations, Corporate Compliance Plan or the Code of Conduct & Conflict of Interest Policy may result in disciplinary action, up to and including termination of employment or engagement with The Center for Family Support.

By placing a checkmark in the boxes above I acknowledge that I have read and understand each statement. Full Signature ____________________________________________________ Print Full Name ___________________________________________________ Full Title_________________________________________________________ Full Date_________________________________________________________ Acknowledgement Compliance Plan

CENTER FOR FAMILY SUPPORT, INC. Corporate Compliance Plan, Code of Conduct & Conflict of Interest Policy Disclosure Statement In accordance with The Center for Family Support’s (CFS) Code of Conduct & Conflict of Interest policy, a conflict of interest is defined as: Any situation in which financial or other personal considerations may compromise or appear to compromise (1) business judgment, (2) the delivery of services or (3) ability to carry out the responsibilities of one’s position/role within CFS. An actual or potential conflict of interest occurs when an employee or Board member is in a position to influence a decision that may result in a personal gain for that individual or for a friend or relative as a result of business dealings. The purpose of the CFS Code of Conduct & Conflict of Interest policy is to insure that all decisions made by employees and Board members are motivated solely by concerns for the interest of The Center for Family Support, Inc. When a conflict of interest exists for an employee or Board member on a particular issue, he or she may not participate in the decision. Where CFS has a business relationship with an employee or Board member directly or an entity in which an employee or Board member has an interest, no preferential treatment shall be given to the employee or Board member or any such entity as a result of such relationship. Where an employee, Board member or a member of his or her immediate family receives services from The Center for Family Support, no preferential treatment shall be given to that senior manager or any such family member in connection with the rendition of services. Please complete this disclosure form. Disclosure statements are intended to provide the Board and CFS management staff with a systemic and ongoing method of disclosing and ethically resolving potential conflicts of interest. Any conflicts or potential conflicts indicated below will be reviewed by the Human Resources administration and after careful consideration and consultation with Program administration, actions will be taken to reduce or eliminate such conflicts, as warranted. While it is not possible to list every circumstance giving rise to a possible conflict of interest, the following will serve as a guide to the types of activities that might cause conflicts and that must be reported: A. Outside Interests: Definition: To hold directly or indirectly, a position or a financial interest in any outside company, place or vendor from which the individual has reason to believe that CFS secures goods or services (including the buying or selling of stocks, bonds or other securities), or that provides services that are competitive with those of CFS. To compete, directly or indirectly, with CFS in the purchase or sale of property or property rights, interests or services. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ Conflict of Interest Disclosure Statement

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B. Outside Activities: Definition: To render directive, managerial, or consultative services to any outside company, place or vendor that does business with, or competes with the services of CFS or to render other services in competition with CFS. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ C. Inside Information: Definition: To disclose information relating to CFS business for the personal profit or advantage of the individual or his/her family member or friend. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ D. Gifts, Gratuities and Entertainment: Definition: To accept gifts, excessive entertainment, or other favors from any outside company, place or vendor that does, or is seeking to do business with, or is a competitor of CFS under circumstances from which it might be inferred that such action was intended to influence or possibly would influence the individual in the performance of his/her role and/or duties. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ E. Family: Definition: A family member is defined as a grandparent, parent, spouse, child or spouse of a child, brother, sister, or spouse of a brother or sister, cousin, aunt, uncle, mother-in-law, father-in-law, brother-in-law or sister-in-law. Conflicts of interest may arise when: 1. A member of the family is paid directly for services rendered to The Center for Family Support. 2. A member of the family has an ownership or other substantial financial interest in a company, which does business with The Center for Family Support. This provision shall not apply to routine stock ownership in public companies in which such person owns less than 5% of the outstanding shares. 3. A member of the family is employed by a company with which The Center for Family Support does business. This provision shall not apply to nonmanagerial employees or employees without ownership interest in such company. Conflict of Interest Disclosure Statement

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4. A member of the family receives services from The Center for Family Support. 5. A member of the family is employed by the Center for Family Support. Indicate position/title of your family member and the department in which they currently work. ____________________________________________________. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ F. Other: All staff and Board members shall disclose any other such personal, financial or business interests, which constitute conflicts of interest. Disclosure: ( ) None, I have no such conflicts. ( ) Yes, I have such conflicts. Explain here: ___________________________ ________________________________________________________________ ________________________________________________________________

Print Full Name of Individual: ______________________________ Full Signature of Individual: Full Title of Individual: Full Date:

________________________________________

______________________________________________

_____________________

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Conflict of Interest Disclosure Statement

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