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Conflict of Interest Disclosure Statement Form

2. Madison County Conflict of Interest Disclosure Statement Form
   For Employees and Class A Contractors

   For Employees and Class A Contractors

4. The Madison County Compliance Policy for Conflict of Interest includes a provision setting forth the standards of conduct expected and required of its Employees (not covered by the County's Code of Ethics) and Class A Contractors (independent contractors that provide direct health and medical services) to disclose all interest which could result in a conflict.
   
   Please be assured that the disclosure requirements are intended to provide the Board and management with a systematic and ongoing method of disclosing and ethically resolving potential conflicts of interest. Although it is impossible to list every circumstance giving rise to a possible conflict of interest, the following will serve as a guide to the types of activities that might cause conflicts that should be fully reported.
   
   This form is to be completed and signed at orientation for employees, and upon Board approval of the contract for Class A Contractors, with a copy sent to the Compliance Officer.

6. A. Conflict of Interest (Definition):
   Any situation in which a financial or other personal considerations may compromise or appear to compromise (1) an employee's or Class A Contractor's business judgement; (2) delivery of services; (3) ability for an employee or Class A Contractor to do his or her job. An actual or potential conflict of Interest occurs when an employee or Class A Contractor is in a position to influence a decision that may result in a personal gain for that employer or Class A Contractor for a relative as a result of business dealings. For the purpose of this policy, a relative shall be defined as a spouse, child, parent, grandparent, grandchild, sister or brother, including step and in-law relations.

   Any situation in which a financial or other personal considerations may compromise or appear to compromise (1) an employee's or Class A Contractor's business judgement; (2) delivery of services; (3) ability for an employee or Class A Contractor to do his or her job. An actual or potential conflict of Interest occurs when an employee or Class A Contractor is in a position to influence a decision that may result in a personal gain for that employer or Class A Contractor for a relative as a result of business dealings. For the purpose of this policy, a relative shall be defined as a spouse, child, parent, grandparent, grandchild, sister or brother, including step and in-law relations.

8. B. Outside Interests:
   (1) To hold, directly or indirectly, a position or a financial interest in any outside concern from which the individual has reason to believe the County secures foods or services (including the services of buying, or selling stocks, bonds, or other securities), or that provides services competitive with the system. (2) To compete, directly or indirectly, with the County in the purchase or sale of property or property rights, interests, or services.

   (1) To hold, directly or indirectly, a position or a financial interest in any outside concern from which the individual has reason to believe the County secures foods or services (including the services of buying, or selling stocks, bonds, or other securities), or that provides services competitive with the system. (2) To compete, directly or indirectly, with the County in the purchase or sale of property or property rights, interests, or services.

10. C. Outside Activities:
    To render directive, managerial, or consultative services to any outside concern that does business with, or competes with the services of the County, or to render other services in competition with the County.

    To render directive, managerial, or consultative services to any outside concern that does business with, or competes with the services of the County, or to render other services in competition with the County.

12. D. Inside Information:
    To disclose or use information relating to the County's business for the personal profit or advantage of the individual or his/her immediate family.

    To disclose or use information relating to the County's business for the personal profit or advantage of the individual or his/her immediate family.

14. E. Gifts, Gratuities, and Entertainment:
    To accept gifts, excessive entertainment, or other favors from any outside concern that does, or is seeking to do, business with, or is a competitor of, the County - under circumstances from which it might be inferred that such action was intended to influence or possibly would influence the individual in the performance of his/her duties.

    To accept gifts, excessive entertainment, or other favors from any outside concern that does, or is seeking to do, business with, or is a competitor of, the County - under circumstances from which it might be inferred that such action was intended to influence or possibly would influence the individual in the performance of his/her duties.

18. I hereby state that I, or members of my immediate family, have the following affiliations or interest and have taken part in the following transactions that, when considered in conjunction with the position with or relation to the County, might possibly constitute a conflict of interest.

20. 1. Outside Interest. Identify any interests, other than investments, of yourself or your immediate family, as described in Paragraph B above. *

    1. I have no conflict of interest to report.
    2. I am reporting the following interests:

22. Please Identify

24. 2. List any relatives/immediate family members currently employed by Madison County or serving as a member its Board of Supervisors. *

    1. I have no conflict of interest to report.
    2. I have relationships to report as follows:

26. Provide full names and relationship to you.

28. 3. Investments. List and describe, with respect to yourself or your immediate family, all investments that might be within the category of “financial interest”, as described in Paragraph B above.*

    1. I have no conflict of interest to report
    2. I am reporting investments that might be within the category of "financial interest" as follows:

30. List and describe:

32. 4. Outside Activities. Identify any outside activities, of yourself or your immediate family, as described in Paragraph C above.*

    1. I have no conflict of interest to report.
    2. I am reporting the following outside activities:

34. Identify any outside activities, of yourself or your immediate family.

36. 5. Other Activities. List any other activities in which you or your immediate family are engaged that may be regarded as constituting a conflict of interest, giving particular attention to the Paragraphs C & D above.*

    1. I have no conflict of interest to report.
    2. I am reporting the following activities:

38. List any other activities in which you or your immediate family are engaged that may be regarded as constituting a conflict of interest

40. 6. Gifts, Gratuities, & Entertainment. I hereby certify that neither I, nor any member of my immediate family, have accepted gifts, gratuities, nor entertainment that might influence my judgment or actions concerning the business of the County, EXCEPT as listed below.*

    1. None to report.
    2. I am reporting gifts, gratuities or entertainment as follows:

42. List gifts, gratuituies and/or entertainment:

44. 7. Code of Conduct. List any circumstances that may possibly violate the Madison County Code of Conduct.*

    If there are none, type "None".

46. Attach additional pages as necessary.

48. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your disclosure statement form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
50. Electronic Signature*

51. Today's Date*
    Today's Date

53. First Name*

54. Last Name*

56. Title

57. Email Address*

59. Department or Business Contractor Name*

Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

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