Supplier Conflict of Interest Questionnaire

Policy Statement
One of the most important assets of our health care organization is our reputation within the community we serve. Our reputation is not
solely based on the quality of the medical care that we provide, but also on the community’s perception of the integrity of our organization
and our Representatives. Although dualities of interest are unavoidable, through disclosure of personal interests, Indiana University Health
(“IU Health”) is able to appropriately manage Conflicts of Interests.

Disclosure
If any questions related to Conflict of Interest on the Supplier Registration platform are indicated by a ‘Yes’ response, each individual or
company (“Supplier”) o to provide goods or services to IU Health must complete this form. If a positive response is indicated for any of the
questions below, provide a description of each interest with sufficient detail to allow an evaluation of a possible Conflict of Interest. Include
the identity and relationship to Family Members when their interests are disclosed.

1. Does an IU Health team member own or control 10% or greater interest in the business? No Yes, please explain:

2. Does a near relative of an IU Health team member (spouse, domestic partner or relative of the domestic partner, child, parent, brother,
sister, in-law relatives of the same relationship, step-relatives of the same relationship or other individual residing in a team member’s
home) own or control 10% or greater interest in the business? No Yes, please explain:

3. Will any IU Health team member be paid by the proposed supplier for the proposed transaction or relationship?
No Yes, please explain:

4. Does the Supplier have an association with any IU Health team member or near relative of such person that is in a position of
influence or in a decision-making position related to the business relationship with the Supplier? No Yes, please explain:

5. Has the Supplier entered into any contract, agreement or executed any document whatsoever that will, in any way, prevent it from
giving IU Health the benefit of services under the contract? No Yes, please explain:

6. Has the Supplier entered into any contract, agreement or executed any document, which will create a Conflict of Interest, or which
will prevent it from freely performing any provision of the contract or agreement signed with IU Health? No Yes, please
explain:

Acknowledgement
By signing this Supplier Conflict of Interest Questionnaire, a Supplier guarantees that:
• The Supplier has disclosed any potential Conflict of Interest which could prevent it from acting in the best interest of IU Health and
that such a situation will not exist during the term of the contract or agreement.
• If a Supplier has any doubt as to whether a Conflict of Interest exists, it must disclose the same to IU Health.
If a Supplier is found to be in non-compliance with this document, it may be subject to termination of services.

_________________________________________ _________________________________________ _______________________________

Supplier Signature Name (please print legibly) Date

_________________________________________ _________________________________________ ______________________________

IU Health Business Owner Signature Name (please print legibly) Date

The IU Health Business Owner signature indicates that leadership acknowledges and is aware of the Supplier’s disclosed interests and
that leadership does not regard the interest(s) as creating a Conflict of Interest that unduly affects the Suppliers actions or judgments on
behalf of IU Health or IU Health patients. The IU Health Business Owner signature indicates that he/she is prepared to work with
Corporate Compliance to manage any Conflicts of Interest as may be appropriate. If the IU Health Business Owner leadership does not
feel comfortable signing the Supplier Conflict of Interest Questionnaire as indicated, notify Corporate Compliance.
Forward completed questionnaire to IU Health Business Owner.

Supplier Conflict of Interest Questionnaire