Harmony Heights Conflict of Interest Disclosure & Acknowledgment Form
Disclose actual, potential, or perceived conflicts of interest and acknowledge your responsibilities.
Workforce Member Information and Expectations
Purpose: This form helps Harmony Heights Home Health Services LLC identify and appropriately manage actual, potential, or perceived conflicts of interest. Disclosure does not automatically mean that a conflict is prohibited; it allows the company to review the circumstances and determine appropriate next steps.
Employee/Workforce Member Name
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First Name
Middle Name
Last Name
Job Title/Position
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Department/Location
Date of Disclosure
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. CONFLICT OF INTEREST EXPECTATIONS
A conflict of interest may exist when a personal, financial, family, business, or outside interest could interfere with - or reasonably appear to interfere with - an individual's judgment, responsibilities, loyalty, or decision-making on behalf of Harmony Heights Home Health Services LLC or its clients. Employees and other workforce members are expected to avoid improper personal gain, protect client interests, maintain professional boundaries, and promptly disclose situations that may create an actual, potential, or perceived conflict of interest.
Disclosure Questions
1. Do you, your spouse, domestic partner, or an immediate family member have an ownership, investment, employment, consulting, or other financial interest in a company that does business with, seeks to do business with, refers clients to, receives referrals from, or competes with Harmony Heights?
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Yes
No
2. Do you have outside employment, self-employment, a side business, board role, consulting role, or other activity that could interfere with your work schedule, responsibilities, objectivity, or loyalty to Harmony Heights?
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Yes
No
3. Do you have a personal, family, romantic, or close financial relationship with a client, client representative, vendor, referral source, contractor, coworker, supervisor, or applicant that could affect - or appear to affect - a business, scheduling, hiring, care, purchasing, or other work decision?
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Yes
No
4. Have you accepted, requested, offered, or been promised money, gifts, favors, discounts, loans, services, entertainment, or other benefits that could influence - or appear to influence - your professional judgment or work decisions?
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Yes
No
5. Do you have any financial arrangement with a client or client family, including borrowing or lending money, receiving personal payments, buying or selling property, being named in a will, acting under a power of attorney, or handling funds outside authorized job duties?
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Yes
No
6. Are you involved in selecting, supervising, evaluating, scheduling, hiring, referring, contracting with, or approving payments for any person or business with whom you have a personal, family, or financial relationship?
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Yes
No
7. Are you using, or do you plan to use, Harmony Heights property, confidential information, client information, work time, business opportunities, vendor relationships, or other company resources for personal benefit or for another business?
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Yes
No
8. Are you aware of any other situation that could reasonably create an actual, potential, or perceived conflict between your personal interests and your responsibilities to Harmony Heights or its clients?
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Yes
No
Disclosure Details
3. DISCLOSURE DETAILS - COMPLETE IF YOU ANSWERED YES TO ANY QUESTION
Please describe the relationship, outside interest, company/person involved, relevant dates, financial or personal interest, and how the situation relates to your Harmony Heights responsibilities.
Person, organization, business, or relationship involved
Nature of the conflict or potential conflict
Your role or financial/personal interest
How this may affect or appear to affect your work responsibilities
Proposed steps to avoid or manage the conflict (if known)
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Employee Acknowledgment and Signature
4. EMPLOYEE ACKNOWLEDGMENT — By signing below, I certify that the information I provided on this form is true and complete to the best of my knowledge. I understand that I have an ongoing responsibility to promptly disclose any new or changed circumstance that may create an actual, potential, or perceived conflict of interest.
Disclosure status
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I have no conflict of interest to disclose at this time.
I have disclosed one or more actual, potential, or perceived conflicts above.
Acknowledgments
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I understand that I should not make, influence, or participate in a decision involving a disclosed conflict unless Harmony Heights has reviewed the matter and authorized my participation.
I understand that Harmony Heights may require safeguards, reassignment of responsibilities, recusal from decisions, discontinuation of an outside arrangement, or other reasonable steps to manage a conflict.
I understand that failing to disclose a known conflict or violating an approved conflict-management plan may result in corrective action consistent with company policy and applicable law.
Employee/Workforce Member Signature
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employee ID (if assigned)
Submit
Submit
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