ODYSSEY HOUSE CONFLICT OF INTEREST DECLARATION

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Name*

First NameLast Name

Position Title*

You may need to refer to your most recent Offer Letter. If you are still not sure, please reach out to the Onboarding Team at onboarding@odysseyhouse.org

Department*

You may need to refer to your most recent Offer Letter. If you are still not sure, please reach out to the Onboarding Team at onboarding@odysseyhouse.org

DATE*

Date

Odyssey House Email*

Confirmation Email

Please review the Odyssey House Conflict of Interest policy and answer the following questions to the best of your knowledge. While these questions revolve around common scenarios in which potential conflicts of interest may arise, they do not include all scenarios. Communicate any questions or concerns with a member of the People Team.

1. Do you engage in a business venture with an organization that is:

(a) conducting business with Odyssey House?*

YesNo

(b) soliciting business from Odyssey House?*

YesNo

2. Do you participate in outside volunteer services that are involved with the programs or clients of Odyssey House, including service on a policy making or advisory board of an institution / agency which contracts with or provides services for Odyssey House?*

YesNo

3. Do you have outside employment or volunteer responsibilities that would:

(a) impair independent judgment in performance of Odyssey House duties?*

YesNo

(b) impair your ability to perform your job at full capacity?*

YesNo

(c) interfere with the ethical performance of your duties?*

YesNo

4. Do you have personal investments or ownership interest in any business where a potential conflict might occur between your private interests and work duties?*

YesNo

5. Will you engage in outside work or volunteer / unpaid service for another employer or organization during working hours at Odyssey House?*

YesNo

6. If you are a full-time employee at Odyssey House, do you have outside employment in which you must work an average of 20 or more hours per week?*

YesNo

7. Do you have a previous personal relationship with a current client (including those relationships involving substance use, sexual involvement, and / or any other significant relationship history)? If so, is / was this relationship:*

YesNo

If so, is / was this relationship...

(a) based on outside paid employment?*

YesNo

(a) conducting business with Odyssey House?*

YesNo

(b) with an individual who has been an Odyssey House client within the past 6 months?*

YesNo

8. Will you directly supervise individuals with whom you have external relationships (family, shared external investments, ties to your household, etc)?*

YesNo

9. Do you have a relation by blood or marriage to a director, Board Member, or officer of another similar organization serving the same population as Odyssey House?*

YesNo

10. Do you have any other possible conflicts of interest that have not already been asked about, but may still be indicated in Odyssey House's Conflict of Interest policy?*

YesNo

11. If any of the questions above are marked YES, provide a detailed description below.*

Include relevant information such as the names of outside entities, activities, decision-making authority, individuals, and types of relationships that might cause a potential conflict of interest.

By signing below, you attest that you have…

● read Odyssey House’s Conflict of Interest policy (p 15 of Personnel Manual);

● disclosed any and all potential conflicts to the best of your knowledge; and

● understand that the following situations cannot be considered for approval:

○ Using, or attempting to use, your position within Odyssey House to secure special privileges or exemptions for yourself or others.
○ Using your position and authority to influence or affect the outcome of an election or nomination during work time or during off time.
○ Soliciting political contributions from anyone during hours of employment.
○ Engaging in political activity during work time.
○ Compromising work responsibilities to expedite outside personal gains.
○ Disclosing information acquired by your position to privately benefit yourself or others.
○ Utilizing agency resources and / or materials for purposes other than those required in your position.
○ Developing non-professional or non-work related relationships with clients.
○ Exploiting your position over other employees for personal favors and / or gain.

Employee Signature*

Date Signed*

Date

Hour MinutesAM/PM Option

Directors and Administrative Personnel Only

Director / Administrative Email

example@example.com

If any potential conflicts of interest exist, what actions will be taken to ensure conflicts will not occur / continue?

Consider any potential conflicts of interest and associated resolutions, then indicate your approval below.

ApprovedDenied

Director or Reviewer Signature

Date Signed

Date

Hour MinutesAM/PM Option

Odyssey House, Inc. 117 West 400 South, Salt Lake City, Utah 84101 Human Resources: 1-801-436-7331 people@odysseyhouse.org 2/2