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Confidentiality and conflict of interest declaration
1
Intro
2
Personal
3
Confidentiality
4
Conflict of Interest
5
Agreement
6
Submit
This form is used to declare conflicts of interest and to acknowledge obligations in relation to maintaining the confidentiality of information obtained in the performance of TASC duties. This form must be completed by all persons employed under the
State Service Act 2000
to work for, or on behalf of, TASC.
Before completing this form you
must
read:
the
Conflict of Interest Policy and Procedure
the
webpage on Conflict of Interest
the
State Service Code of Conduct
, outlined in section 9 of the
State Service Act 2000
.
This declaration is governed by the law for the time being in force in the State of Tasmania.
Your personal information will be used for the purpose for which it was collected in accordance with the
Personal Information Protection Act 2004
. A full personal information protection statement relevant to TASC is provided at
www.tas.gov.au/stds/pip.htm
.
This declaration is made on the day it is submitted to TASC:
By: (name)
*
First
Last
Email
*
Of: (address)
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
For the role of:
*
Setting Examiner
Critic - Examination Papers
Observer
Marker
Marking Coordinator
External Assessment Supervisor
External Assessment Supervisor Coordinator
Clerical Assistant (Band 1)
Administrative Assistant (Band 2)
Voice Actor
Non sessional staff
I declare that:
*
I understand that I am subject to the
State Service Act 2000
while carrying out my duties for TASC.
*
I have read the
State Service Code of Conduct
, contained in the
State Service Act 2000
and understand its application to the duties of my role with TASC.
*
I will use all reasonable endeavours to secure all confidential information in my possession, or control against loss and unauthorised access, use, modification or disclosure.
*
I will not disclose any information obtained while carrying out my duties for TASC for personal or commercial purposes.
*
I will return all TASC documents, data and equipment to TASC on the completion of my duties.
Declaration
*
I have read and understand TASC's
Conflict of Interest Policy and Procedure
.
I declare that I have:
*
No conflict
an
actual
conflict
a
perceived
conflict
a
potential
conflict
Refer to the
Conflict of Interest Policy and Procedure
for detail on each type of conflict.
My conflict(s) of interest is (are):
*
pecuniary
non pecuniary
The following people will gain a benefit as a result of my decisions / actions in my TASC role:
*
Me or my immediate family
My friends or associates
Companies / Trusts / Associations
Other
No person will benefit
Please specify 'other':
Please outline the nature the your conflict(s) of interest:
*
Describe the reason you have a conflict, or the circumstances that lead to the conflict. Include specific names, dates, courses or schools as appropriate.
Describe how your conflict(s) of interest might influence, or be perceived to influence you in carrying out your assigned duties within TASC:
*
Think carefully and broadly about where your specific points of vulnerability are, in relation to your conflict(s) of interest. This will help you make sure your Conflict Management Plan (below) will be effective in protecting you and TASC in relation to the conflict(s) of interest.
Conflict Management Plan
*
Outline how you propose to manage / resolve / eliminate / avoid the conflict(s). What measures or arrangements will you put in place?
I agree to:
Declaration
*
Update this Confidentiality and Conflict of Interest Declaration each calendar year during my employment with TASC and at such times as there are changes to my circumstances that impact the conflict(s) of interest that exist.
*
Implement and comply with my Conflict Management Plan, as required.
*
Comply with any conditions or restrictions imposed by TASC to manage or eliminate an actual, potential or perceived conflict of interest.
If a situation arises that results in an unforeseen conflict of interest, or a breach of my Conflict Management Plan or other conditions or restrictions that are imposed by TASC, I agree, as soon as possible, to:
*
Take reasonable steps to remove myself from the situation.
*
Report the situation to TASC or a TASC representative.
Declaration:
*
I confirm that the information given in this declaration is true, complete and accurate to the best of my knowledge.
Thank you. To submit your confidentiality and conflict of interest declaration to TASC, click the
Submit Declaration
button.
