2 External Reviewer Conflict of Interest Form

C onfidentiality and Conflict of Interest Form
FY YYYY AmeriCorps state and National Grants Competition

Instructions:

1. Read this form to understand your responsibilities regarding confidentiality and potential conflicts of interest.

2. Fill out the PDF Form (or print), initial, sign, and date the last page.

3. Return the signed last page to AmeriCorps by 12pm Eastern on MM/DD/YYYY . Email the signed copy to [email protected] with ATTN: FY YYYY ASN Competition Review.

4. Check your assigned applications for any perceived or actual conflicts of interest.

5. If you identify a potential conflict of interest, you must immediately notify GARP Liaison at [email protected].

As a participant in an AmeriCorps Grant Application Review Process (GARP), you are required to abide by the following requirements regarding maintaining the confidentiality of information obtained as part of this GARP and disclosing any possible conflict of interest as a GARP participant.

Confidentiality of Information

• As part of this GARP review, you will have access to information that is not available to the public, and you have special professional and ethical responsibilities to maintain the confidentiality of that information. You may use the information we give you about applicants only during the review process and in discussions with fellow review participants and AmeriCorps staff.

• After AmeriCorps announces awards, we may disclose information that we provided to you (or that you produced) while you participated in this review. If AmeriCorps does not reveal this information, you may not either. You must keep confidential any information you received or produced during this review.

• You may not use information provided to you during this review for your personal benefit or to make it available for the benefit of any other individual or organization. You may only use the information to fulfill your specific responsibilities as a part of this review process.

• After you complete your participation in this review, and consistent with your normal practices, you may (but are not required to) maintain archival hardcopy or electronic copies of any such information.

  • If you keep any archival copies, you must maintain them in a manner consistent with your confidentiality obligations. Likewise, if you do not keep any archival copies, you must dispose of the information in a manner consistent with the confidentiality obligations stated in this document.

  • Any archival copies of information you retain must be provided upon request to AmeriCorps, its Inspector General, the Government Accountability Office, or any other request made pursuant to a competent legal authority.

Confidentiality of Review Participants

• As a participant in this review process, you may not disclose the names of other participants to applicants or anyone else.

• AmeriCorps reserves the right to publish the names of external reviewers who completed the review process. This list would be published on AmeriCorps’ Results of Grant Competitions webpage and is consistent with agency policy.

• AmeriCorps does not release the names of reviewers when distributing and/or publishing the review products that may result from this review process.

Conflict of Interest

• For purposes of this review, a Conflict of Interest is any private interest, affiliation or relationship which could potentially compromise your ability to impartially carry out your official responsibilities. Examples of potentially biasing affiliations or relationships are listed below.

• Before you review any grant applications, you must tell AmeriCorps about any possible Conflicts of Interest or even the appearance of a Conflict of Interest.

• The duty to disclose potential Conflicts of Interest is an ongoing duty. If a Conflict of Interest or the appearance of a Conflict of Interest arises during the course of your participation, you must tell AmeriCorps.

All Review Participants must disclose any possible Conflicts of Interest in advance of the Review Process. If you become aware of a potential conflict once the Review Process has begun, you are required to alert AmeriCorps staff immediately and provide relevant information to assist in the determination. AmeriCorps staff will review the information, make a determination as to whether there is a conflict, and notify you of what steps, if any, need to be taken.

What are the potential conflicts of interest that I must disclose to AmeriCorps?

You must disclose whether you or any related person has a potentially conflicting relationship with an applicant organization application, or any affiliated organization.

Who are the related persons for whom I must disclose any potentially conflicting relations?

In addition to any potentially conflicting relations you may have, you must disclose any potentially conflicting relationships involving—

• your spouse, domestic partner, or civil union partner

• your minor child

• a relative living in your immediate household.

• any person you are employed by or that you are seeking employment with.

What are the affiliated organizations for which I must disclose any potentially conflicting relationships?

In addition to any potentially conflicting relationships you or a related person may have with an applicant organization, you must disclose any potentially conflicting relationship with—

• any known partners or organizations which are collaborating with the applicant regarding the current application

• any known former sub-recipient of the applicant organization

• any known organization that will likely become a sub-recipient of the applicant organization if the present application receives funding.

What are the potentially conflicting relationships that I must disclose?

You must disclose when you or a related person—

• has submitted an application in the present competition, or was personally involved in preparing an application

• could personally benefit if an application submitted in the present competition is selected to receive funding

• are currently being considered for employment, or (within the last 12 months) had an employment, consulting, advising, or other similar affiliation with the organization

• holds any office or membership on the organization’s governing board, visiting committee, or similar body

• directly own any securities or evidence of debt of the organization

• has a financial interest that would be affected by the outcome of this grant competition

• is a currently enrolled student (in the case of an organization that is an educational institution)

• has received and kept an honorarium or award from the organization within the last 12 months

• has collaborated on a project or on a book, article, report, or paper with the organization within the last 12 months, or

• had any other past or present business, professional, academic, volunteer, or other personal relationship with the organization that could reasonably call into question whether you can objectively participate in the current grant application review process.

Instructions:

1. Fill out the PDF Form (or print), initial, sign, and date this page.

2. Email a signed copy of this page to [email protected] with ATTN: FY YYYY ASN Competition Review by 12pm Eastern on MM/DD/YYYY.

Please initial each item before signing below:

[______] I have read this form and understand I must contact the appropriate AmeriCorps official in regard to any potential Conflict of Interest.

[______] I will not divulge any confidential information I may become aware of as a result of my participation in this grant application review process.

[______] I fully understand that I must sign and return this Confidentiality and Conflict of Interest form to AmeriCorps, and that my compliance with the requirements stated on this form is required in order to receive any honorarium from AmeriCorps.

Name (printed):
Signature:		Date (MM/DD/YYYY):
Review Title:
FY YYYY ASN Competition
For AmeriCorps Review Coordinator Use
Comments

PUBLIC BURDEN STATEMENT: Public reporting burden for this collection is estimated to average 45 minutes per submission, including reviewing instructions, gathering and maintaining the data needed, completing the form, and reviewing the collection of information. Comments on the burden or content of this instrument may be sent to AmeriCorps, Attn: Amy Borgstrom, 250 E. Street SW, Washington, D.C. 20525. You are not required to respond to the collection unless the OMB control number and expiration date displayed on page 1 are current and valid. (See 5 C.F.R. 1320.5(b)(2)(i).)