Ethics- Conflicts of Interest- Policy Questions Form

Ethics- Conflicts of Interest- Policy Questions Form

Please select the type of form you would like to submit: Ethics Inquiries and Questions Web Form Conflict of Interest Disclosure Form DHS Policy Questions For questions or concerns, contact the Ethics Officer Nikki Thompson at 651-431-4248 or DHS_Ethics_Questions@state.mn.us (see link below). More guidance for employees is provided in the DHS Ethics and Conflicts of Interest Policies in the links below.

Information about the Ethics Web Form

Ethics questions are confidential unless the circumstance rises to the level requiring reporting and routing. A record ID number will be generated when you submit the web form and can be used to follow-up with the Ethics Office. Every submission is reviewed by the Ethics Officer. Answers to common ethics questions are published on the Ethics Box Questions and Responses (see link below). Answers to ethics questions that are unique, complex or require more information are not published on this page. This form is truly anonymous. Therefore, if you choose to remain anonymous the Ethics Office is unable to respond directly.

Tennessen Warning

The purpose of this form is to collect information regarding potential or actual conflicts of interest. You are not legally required to provide the data below, but if you do not provide the requested data you may fail to comply with DHS’ ethics policies, including but not limited to the Reporting Ethical Violations policy, and may be subject to discipline, up to and including termination. If you provide the data, it will be used to review and record potential or actual conflicts of interest relating to the subject(s) of the report and/or relating to your work at DHS. The data may be shared with: the subject(s) of the report; DHS employees whose work assignments reasonably require access, including but not limited to the DHS Ethics Office, Internal Audits, Human Resources, the report subject(s)’ supervisor(s) or manager(s), and your supervisor or manager; the State or Legislative Auditor; the Attorney General; Minnesota Management and Budget; law enforcement agencies with statutory authority; and/or any other person or entity authorized by state or federal law or court order to access the data.

Information about the Conflict of Interest Disclosure Form

Employees are responsible for recognizing and avoiding situations that result in or appear to be a conflict of interest. Employees should consult with their supervisor if they have questions or believe they may have a conflict of interest. If preferable, employees may consult the Ethics Officer instead. If a potential or actual conflict of interest exists at any time while employed by DHS, employees must disclose it by completing this form as soon as possible. More information on Conflicts of Interests are available for employees in the DHS Conflicts of Interest Policy. Every employee is required to follow Minnesota Statute section 43A.38, Code of Ethics for Employees in the Executive Branch, Minnesota Management and Budget statewide ethics policies and DHS ethics policies.

Conflict of Interest Disclosure Form

1. Employee Name 2. Job Title 3. Phone Number 4. Date 5. Division 6. Administration Children and Family Services Community Supports Continuing Care Direct Care and Treatment Health Care Operations Other Unknown 6a. If other was selected, please describe 7. Type (select all that apply) Outside employment Volunteer activity Board participation Contract involvement Other 8. Describe your work inside the agency (current position, projects, work groups, etc.). 8a. Attach any supporting documentation (current position description, project or workgroup charter, etc.). 9a. Attach any supporting documentation. 9. List the relevant individual(s) and organization(s) involved and explain your relationship to the individual(s) and organization(s) (professional, personal, past and current, etc.). 10. List and explain any economic interests. 10a. Attach any supporting documentation. 11. Describe the situation or activity that may need a conflict of interest review. Include background and any relevant information. 11a. Attach supporting documentation (description or information on situation, activity, event, organization, etc.). By submitting this form, you acknowledge that you read the Tennessen Warning above, and all the information on this form is accurate to the best of your knowledge.

General Information We Need From You

Do you wish to remain anonymous for this report? Yes No What is your relationship to the MN Department of Human Services? (Required) DHS Employee Client Contractor/Third Party/Vendor Recipient External Stakeholder Community Member Volunteer or Intern Business Area or Division First Name Last Name E-mail Phone Number

Ethics Information

Please identify the administration involved: Children and Family Services Community Supports Continuing Care Direct Care and Treatment Health Care MN.IT Operations Other Unknown Describe your ethics concern or question with as much as detail as possible, include the following information: • date • location • person(s) involved Please identify the business area/division involved: Ethics Concern or Question: Subject* From Address* Description* Tenant 22 From name* By submitting this form, you acknowledge that you read the Tennessen Warning above, and all the information on this form is accurate to the best of your knowledge. Application Type Hotline Ethics and Conflicts of Interest EOA Investigations

DHS Policy Questions

DHS Policy Question or Suggestion Type Clarification on policy, procedure, standard or form Looking for a policy, procedure, standard or form New suggestion on policy, procedure, standard or form Other If other, please describe below DHS Policy Question or Suggestions