Conflict of Interest Declaration and Management Plan

Part 1 – To be completed by the person making the declaration

Section 1 – Personal Details
Engagement type (please select):

o Commissioner o Expert Advisory Panel o Staff

Name: Albert Diaz

Position: Counsellor

Preferred Contact Number: 0413012535

Section 2 – Disclosure
Please refer to the conflict of interest policy for the definitions of personal interest, material relationship
and conflict of interest, or contact: Lisa Tricarico – Manager Human Resources:
lisa.tricarico@yoorrook.org.au

Do you think any of your interests or relationships could pose an actual, ☐Yes
☒ No (go
perceived or potential conflict of interest (this could be previous or current (include to
outside employment, other commitments, benefits, relationships, publications details Section
in accordance with the policy). below) 3)
Please fill out the details of any interests below (please list separately and add detail where the conflict may not
be obvious):

Section 3 - Declaration
To the best of my knowledge and belief, any actual, perceived or potential conflicts between my duties for Yoorrook and my
private and/or business interests, have been fully disclosed in this form. I acknowledge, and will work with Yoorrook to comply
with, any approach identified for removing or managing an actual, perceived or potential conflict of interest.

Albert Diaz 13/2/24

Signature: Date:

OFFICIAL
 Part 2 – To be completed by the Manager Human Resources – (Reviewed by CEO
or Commissioners in accordance with policy)

Section 4 – Assessment of the disclosure

In my opinion, in relation to the disclosure provided (check appropriate box):

☐ No conflict was identified, and no further action is required (Go to Section 6)

☐ Does constitute an actual, potential or perceived Conflict of Interest in the context of the factors below:
(Go to Section 5)

 Whether the conflict needs to be avoided or simply documented;

 Whether the conflict will realistically impair the disclosing person's capacity

to impartially participate in decision-making and the general work of Yoorrook,

having regard to the role of the particular individual;

 alternative options to avoid the conflict;

 Yoorrook's objectives and resources;

 The possibility of creating an appearance of improper conduct that might impair

confidence in, or the reputation of, Yoorrook.

Section 5 – Suggested Management plan

Where the situation does involve a possible Conflict of Interest, the following has been considered:
▪ Ensuring all information surrounding the conflict has been disclosed and documented

▪ Informing affected persons of any alternative arrangements being implemented in light of an identified
Conflict of Interest

▪ Implementing additional oversight arrangements

▪ Reformulating the person’s scope of work, or restricting access to certain information

▪ Relinquishing the interest that is causing the conflict

▪ (In exceptional cases) removing the person from their existing duties, or transferring the person to other work

▪ Taking no further action because the conflict is minimal

I have reviewed the above considerations and recommend that the following actions are taken to eliminate/
manage the conflict:

This plan will be reviewed (check appropriate box):

☐ Within Month/s ☐ N/A as the conflict is a one off of

short duration

OFFICIAL
 Section 6 – CEO/Yoorrook Chair declaration:
Please select one of the following:
 I have reviewed the declaration and proposed actions and agree with the recommendations in
accordance with the policy. I have delegated implementation to the appropriate person.

 I have reviewed the declaration and proposed actions (and where appropriate cast a vote with
Commissioners) however have made the following amendments to the management plan. I have
delegated implementation to the appropriate person.

Add amendments here:

Name: (Printed)

Signature: Date:

This form will be held on the Yoorrook personnel files. Information from this form will be added to the Conflict of
Interest register and maintained by the Manager Human Resources.

OFFICIAL