OFFICIAL – SENSITIVE (WHEN COMPLETE)

Department of Health and Social Care – Declarations of Interest Form

First Name: Last Name: Job Title:

Grade: Line Manager: Directorate: DG Group:

Declaration of Interest Details – refer to conflicts of interest and code of business

conduct for guidance.

Nature of declaration:

The potential conflict and the parties involved

(Describe why there is a conflict and name the individuals or organisations involved)

Likely duration of conflict

(Explain if this will be an ongoing conflict or specific to a particular investment decision)

Managing the potential conflict

(N.B. Line Manager, Head of Function or Executive Director to provide details of how the potential conflict will
be managed)

OFFICIAL – SENSITIVE (WHEN COMPLETE)

 OFFICIAL – SENSITIVE (WHEN COMPLETE)

Signature of Line Manager, Head of Function or Executive Director

……………………………………………………… Date……………..

Signature of person making this declaration

Date…………
…………………………………

I have been given a copy of, and have read and understood the Conflicts of
Interest and Code of Business Conduct policies and I agree to abide by those
provisions. I declare to the best of my knowledge and belief, that I have no
declarations of interest other than those set out in this form and that the
information given within this form is correct.

OFFICIAL – SENSITIVE (WHEN COMPLETE)