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CJAC Conflict of Interest Notification

  1. Purpose
    The purpose of this form is for CJAC Members to alert AACOG staff of any Conflict of Interest for CJD grant applications. Conflict of Interest includes but is not limited to a CJAC Member or CJAC Member relative: 1. Is employed by the applicant agency and/or works for the unit, division, department, etc. that would administer an awarded grant; 2. Services on any board that oversees the agency and/or unit, division, department, etc. that would administer an awarded grant; 3. Owns or controls any interest in a business entity or other non-governmental organization that benefits directly or indirectly from an agency's activities from an awarded grant; and/or 4. Receives any funds, a sustainable amount of tangible goods, or services the applicant agency as a result of an awarded grant.
  2. Membership*
  3. Please include department/division/unit, if applicable.
  4. Optional: Grant funding streams with Conflict of Interest
    If you aware of which funding streams you have conflict of interest in, please select all that apply. You may skip this question if you do not immediately know.
  5. Certify*
    I confirm that I will not review, score, or recommend funding for my conflicted application(s) or any applications within the same funding stream. I additionally acknowledge that I will not participate in any discussion with CJAC Members concerning my conflicted application(s) and I will leave the Scoring Meeting during my application's allotted time.
  6. Leave This Blank:

  7. This field is not part of the form submission.