Disclosure of Family & Business Relationships

International Medical Corps’ Conflicts of Interest Policy provides that:

1. Staff may not participate in the selection, award, or administration of a contract if an actual or
potential conflict of interest 1 would be involved.
2. Staff may not be involved in hiring or directly supervising immediate family members.
3. Staff may not offer, promise, solicit or accept gratuities, favors, or anything of monetary
value from individuals or organizations doing or seeking to do business with International
Medical Corps, this includes vendors, recipients, donors, and government officials.
4. Staff may not use any information learned at International Medical Corps for personal gain or to
compete with International Medical Corps.

Staff should also avoid the appearance of a conflict of interest between their work for International
Medical Corps and their personal life, and should always disclose (on this form or otherwise in writing
to Human Resources) when they are involved in a hiring, promotion, or procurement process and
personally know one of the applicants or vendors.

Staff must disclose all known actual and potential conflicts of interest to International Medical Corps
through this form, and must disclose future actual or potential conflicts when they arise to Human
Resources so that any necessary actions can be taken. Once a conflict of interest is disclosed, it can often
be avoided or resolved. For example, a procurement staff member related to a vendor may be removed
from working on any transactions with that vendor.

Do you have any actual or potential conflicts of interests? (Check one)

No.
_____ Yes, I have the following actual or potential conflict(s) of interest to report (please specify):

I understand that I have an ongoing duty to disclose all actual and potential conflicts of interests through
this disclosure form or directly to Human Resources when an actual (or potential) conflict arises. I have
read and agree to International Medical Corps’ Conflicts of Interest Policy and agree to fully comply with
it at all times during my relationship with International Medical Corps.

Signature Date

Print Name

1
Bold terms are defined/explained on page 2 of this form.
August 2019
Page 1 of 2
Definitions:

Actual conflict of interest: Actual conflicts of interest to be disclosed on this form or as they arise occur when:
 You, your immediate family member, your business partner, your agent (or a company that employs one
of these individuals) has a current or future financial or other interest in the party selected for a contract,
award, or any transaction with International Medical Corps.
 You supervise or are supervised by an immediate family member.
 You are involved in hiring an immediate family member.
 You take an action or have an interest that makes it difficult to perform his or her work objectively and
effectively. This includes offering or accepting gratuities, favors, or anything of monetary value from
individuals or organizations doing (or seeking to do) business with International Medical Corps.
 You use information learned at International Medical Corps for personal financial gain or to compete with
International Medical Corps.
Appearance of a conflict of interest: The appearance of a conflict of interest occurs when the personal interests of a
staff member create the perception that those interests could be different from the staff member’s job duties and/or
the interests of International Medical Corps.
Potential conflict of interest: Potential conflicts of interest to be disclosed on this form or as they arise may include:
 A staff member is supervised (directly or indirectly) by another staff member who is a family member.
This definition is broader than “immediate family member” as defined below and includes all individuals
that the staff member would identify as “family” such as cousin, brother/sister-in-law, etc.
 A staff member or his/her immediate family member is considering a financial or business interest in a
business that International Medical Corps does business with or competes with.
Gratuities, favors, or anything of monetary value: Giving and receiving gratuities, favors, or anything of
monetary value can be viewed as attempts to influence the performance of job duties and may create a conflict of
interest. Gratuities, favors, or anything of monetary value includes cash, gifts (other than those of nominal value),
discounts, loans, entertainment, and free travel or lodging.
Immediate family member: Immediate family means a spouse or domestic partner, child, parent, brothers and
sisters of both you and your spouse/domestic partner, grandparent, grandchild, step-parent, step-child, step-brother,
or step-sister, as well as other relatives who share your home or otherwise are dependent on you or your
spouse/domestic partner for financial support.

Domestic Partner: A domestic partner is someone with whom an individual lives and shares a common domestic
life, but is not married to.

Financial interest: A person has a financial interest in an organization if the person has, directly or indirectly,
through business, investment, or family: (a) an ownership or investment interest in the organization, (b) a
compensation arrangement with the organization or with any entity or individual with which the organization has a
transaction or arrangement, or (c) a potential ownership or investment interest in, or compensation arrangement
with, any entity or individual with which the organization is negotiating a transaction or arrangement.

Other interest: a non-financial benefit that is tangible and results in a personal benefit to the individual such as
improved employment opportunities, business referrals, political influence, etc.

Staff: International Medical Corps directors, trustees, officers, employees, volunteers, interns, consultants, and any
other individual who acts on International Medical Corps’ behalf or at International Medical Corps’ direction.

August 2019
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