Duality of Interest Disclosure Form for Department Managers

Each fiscal year, Department Managers should disclose "any interest which would be inconsistent with the expeditious, proper, and impartial performance of duties," defining disclosable conflict or duality of interest as any matter in which the corporations are "interested which affects the financial interest or employment of such member, a member of his/her family by blood or marriage, or any business enterprise in which he/she or such family member is employed or has a financial interest."

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St. Anthony Regional Hospital FY2019 Duality of Interest Disclosure Form for Department Managers

Department Managers should disclose "any interest which would be inconsistent with the expeditious, proper, and impartial performance of duties," defining disclosable conflict or duality of interest as any matter in which the corporations are "interested which affects the financial interest or employment of such member, a member of his/her family by blood or marriage, or any business enterprise in which he/she or such family member is employed or has a financial interest."

Please answer the questions below and press the Submit Form at the bottom to send. Thank you.

1. Please disclose any employment or contractual relationship between you or members of your immediate family and St. Anthony Regional Hospital or its affiliates.

2. Please disclose all positions or material financial interests which you or members of your family hold in any business or entity from which St. Anthony Regional Hospital or its affiliates secure or might secure goods or services or which provides services competitive with St. Anthony Regional Hospital or its affiliates.

3. Please disclose any other interest, relationship or affiliation of you or any member of your immediate family which you feel you should disclose, keeping in mind that the purpose of this questionnaire is to protect you and St. Anthony Regional Hospital from a charge of a real or apparent conflict of interest.