ETHICAL REPORTING FORM

1

Please select an option:* This field is required.

Disclose Possible Conflict(s) of InterestReport Alleged Ethical Violation(s)

2

Do you wish to remain anonymous?* This field is required.

YESNO

3

Your Name* This field is required.

First Name

Last Name

4

Your Email* This field is required.

example@example.com

5

Select the department(s) where the alleged violation(s) occurred.* This field is required.

6

Name the individual(s) involved in the alleged ethical violation(s): * This field is required.Use "last name, first name - position" format and click "add row" for each additional entry.

7

To your knowledge, how many times has the alleged violation(s) occurred?* This field is required.

Once

More than once

8

Approximately when did the alleged ethical violation(s) occur? * This field is required.Indicate date(s) using MM/DD/YYYY format.

9

Describe the nature of the ethical violation(s).* This field is required.Be as detailed as possible.

10

Upload attachments, if any, that may support your claim:

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

11

Have you reported the alleged ethical violation(s) in the past?* This field is required.

YESNO

12

Previous report details:* This field is required.

First and Last Name of person to whom you reported the alleged violation(s).

Approximate date(s) when you reported the alleged violation(s).

13

A conflict of interest arises when an individual’s personal interests, relationships, or activities have the potential to interfere with their official duties, decisions, or responsibilities.

14

Your Name* This field is required.

First Name

Last Name

15

Your Email* This field is required.

example@example.com

16

Your Position* This field is required.

17

Select your agency* This field is required.

18

Describe in detail any relationships (familial or otherwise), transactions, positions you hold (volunteer or otherwise), and/or circumstances that you believe could contribute to a conflict of interest. * This field is required.

19

Do you have an additional conflict to disclose?* This field is required.

YESNO

20

Describe in detail any relationships (familial or otherwise), transactions, positions you hold (volunteer or otherwise), and/or circumstances that you believe could contribute to a conflict of interest.* This field is required.

21

Do you have an additional conflict to disclose?

YESNO

22

Describe in detail any relationships (familial or otherwise), transactions, positions you hold (volunteer or otherwise), and/or circumstances that you believe could contribute to a conflict of interest.* This field is required.

23

Do you have an additional conflict to disclose?

YESNO

24

Describe any relationships (familial or otherwise), transactions, positions you hold (volunteer or otherwise), and/or circumstances that you believe could contribute to a conflict of interest.

25

The information I have provided in this form is true, complete, and accurate to the best of my knowledge and belief.* This field is required.

Yes, I attest to the statements above.

26

The information I have provided in this form is true, complete, and accurate to the best of my knowledge and belief. Should any additional conflict of interest arise as it relates to my employment in the GVI, I recognize I have a continuing obligation to submit a new Conflict of Interest Disclosure form.* This field is required.

Yes, I attest to the statements above.