FR 28c

DRAFT 8/1/2020
FR 28c
OMB Control No. 7100-0379
Approval expires XXXX

FEDERAL RESERVE BOARD
PRE-HIRE CONFLICT OF INTEREST SCREENING FORM

Name: ________________________

Division: ____________________

Title of job for which you are applying: ______________________
Working for the central bank of the United States carries with it responsibility for maintaining
public trust in the Federal Reserve System. In order to determine whether your financial
interests or outside relationships pose any potential conflicts of interest, we require you to
_____________________________________
provide the information requested below to the extent not previously described on your
_____________________________________________________________
employment application (FR 28), which is hereby incorporated by reference.
Financial Interests: To the best of your knowledge, list any debt or equity interests, such as
stocks or bonds, owned directly or indirectly (such as through a trust) by you, your spouse, or
minor child(ren) in any: bank or bank holding company; savings & loan holding company;
thrifts; consulting firm or law firm advising financial institutions; economic forecasting firm or
other economic consulting firm; or a vendor or contractor that you know works with the Federal
Reserve. In addition, list any interests in a mutual fund or exchange traded fund with a policy of
concentrating in the financial sector.1
  Check here if you have nothing to report for this section.  

Financial Interest

Owner

Relatives in Related Businesses: To the best of your knowledge, disclose any position held by
your spouse, child, parent, or sibling as an employee, officer, director, or trustee of: any bank,
bank holding company, savings & loan holding company, or affiliate of any such entity;
consulting firm or law firm advising financial institutions; economic forecasting or other
economic consulting firm; or a vendor/contractor that you know works with the Federal Reserve.
  Check here if you have nothing to report for this section. 
1

Financial sector funds typically have terms like “Banking” or “Financial” in their names. Diversified funds (e.g.,
large cap funds, S&P 500 funds, targeted retirement date funds) do not need to be reported. If you are unsure about
whether an asset falls into any of these categories, please notify your Board Human Resources representative.

Company or Entity

Position

Relationship

Outside Positions and Activities: A Board employee’s compensated outside employment must
be reviewed and approved by the employee’s division and the Board’s Ethics Office, and some
unpaid positions can raise conflicts of interest concerns. Please disclose below any outside
employment, paid work, or business you plan to engage in if you become a Board employee.
Please also disclose any outside position2 (including an uncompensated position) you plan to
hold while employed by the Board. Do not disclose positions with religious, social, fraternal, or
political entities.
  Check here if you have nothing to report for this section. 

Name of Organization, Employer, or Business

Position

Other Potential Conflicts: In the space below, please disclose any other situations,
arrangements, or investments that you believe could pose a conflict of interest based on the
duties of the position for which you are applying.
  Check here if you have nothing to report for this section. 

_________________________________________
Signature

________________________
Date

I certify that my statements on this form, and any attachments to it, are true, complete, and
correct to the best of my knowledge and belief and are made in good faith.

2

 Reportable positions include officer, director, trustee, general partner, proprietor, representative, employee, or
consultant of any corporation, firm, partnership, or other business enterprise, or any non-profit organization or
educational institution.

Privacy Act Statement
AUTHORITY
The collection of this information is authorized by Section 10 of the Federal Reserve Act (12
U.S.C. § 244), the Ethics in Government Act of 1978, 5 U.S.C. app; the Ethics Reform Act of
1989, Pub. L. 101-194; and 5 C.F.R. 2638.104(c)(2) and (4).
PURPOSE
The Board collects the information you provide on this form in order to manage and document
compliance with the Board’s and the Federal Government’s ethics program requirements.
DISCLOSURE
Furnishing this information is voluntary; however, failure to furnish the requested information
may delay or prevent employment by the Board.
ROUTINE USES
The information you provide will be stored in the system of records entitled BGFRS-1 “FRB—
Recruiting, Onboarding, and Placement Records” and BGFRS-41 “FRB—Ethics Program
Records.” All or part of the information may be disclosed outside the Board in accordance with
routine uses, A, B, C, D, E, F, G, H, I, and J (see “General Routine Uses of Board Systems of
Records available at https://www.federalreserve.gov/files/SORN-page-general-routine-uses-ofboard-systems-of-records.pdf). Furthermore, all or part of the information may be disclosed
outside of the Board in order:
1. To disclose information to any source from which additional information is requested (to
the extent necessary to identify the individual, inform the source of the purpose(s) of the
request, and identify the type of information requested), when necessary to obtain
information relevant to a Board decision to hire or retain an employee, issue a security
clearance, conduct a security or suitability investigation of an individual, classify jobs, let
a contract, or issue a license, grant or other benefit.
Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 0.5 hours per
response, including the time to gather and maintain data in the required form and to review
instructions and complete the information collection. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing
this burden, to Secretary, Board of Governors of the Federal Reserve System, Washington, DC
20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100–
XXXX), Washington, DC 20503. The Federal Reserve may not conduct or sponsor, and an
organization (or a person) is not required to respond to a collection of information unless it displays a currently valid OMB control number.