Ethics- Conflicts of Interest- Policy Questions Form
|
|
|
Ethics- Conflicts of Interest- Policy Questions Form
|
|
| | | |
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
|
|
| | | | | | | | | |
6. Administration |
|
| | | | | |
8. Describe your work inside the agency (current position, projects, work groups, etc.). |
|
| | | | | |
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. |
|
| | | |
11. Describe the situation or activity that may need a conflict of interest review. Include background and any relevant information. |
|
| | | | | |
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
|
|
| |
What is your relationship to the MN Department of Human Services? (Required) |
|
| | | | | | | | | | | | | |
|
Ethics Information
|
|
Please identify the administration involved: |
|
| |
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: |
|
| | | | | |
Description* |
|
| | | |
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 |
|
| | | |
|
DHS Policy Questions
|
|
If other, please describe below |
|
| | | |
|
|