ࡱ> DGC r(bjbj 40ee~ [(((8`4$(z.ZzgL($ Z#pQ4oooLooo9N'^J0z ,#f#9#9poz# : APPENDIX A REPORT OF POTENTIAL CONFLICTS OF INTEREST RELATED TO STUDENTS Complete this form if you answered YES to one or more of Questions 1-2 on the Annual Conflict of Interest/Commitment Statement-Attachment 1. Attach separate sheets and give the answer number for which additional information is provided. Use a separate form to report relationships with each enterprise or corporation. Name:  FORMTEXT       Banner ID:  FORMTEXT       Campus Address Room:  FORMTEXT       Building:  FORMTEXT       Local Address Street:  FORMTEXT       City/State:  FORMTEXT       Zip Code:  FORMTEXT       Rank:  FORMTEXT       Title:  FORMTEXT       Department:  FORMTEXT       Unit:  FORMTEXT       Campus Telephone:  FORMTEXT       Local Phone:  FORMTEXT       Email:  FORMTEXT       Complete Items 1-3 if you answered YES to Question 1 on the Annual Report. Describe the number and levels of the students involved, your financial interest in the business, and how the sponsored project involves the students.  FORMTEXT       Describe the potential benefits to and impacts upon students in working on this project.  FORMTEXT       Discuss the actions or safeguards you will take to prevent your relationships with this enterprise from affecting your responsibilities as a University employee for supervising thes  J ,   4 6 J L N X Z \ ` ּ̭穡s璗csjhhD5UjhD5UmHnHujthhD5U hD5jhD5UhDhD5hDjh5UmHnHujhhU$5Ujh5U h5hjhb5hhbh!ah5hhb5CJaJ$  JK ^ `   Z \ $gdj $gdb ^`gdDgdDgdb$a$gdb 0 2 F H J T V t v   ξήӦΖΎo`jh5UmHnHuj,hhU$5Ujh5U h5hjhb5jhhD5UhDhD5jDhhD5UjhhD5U hD5hDjhD5UmHnHujhD5Uj\hhD5U%  . 0 D F H R T X Z \ p x z  " $ . 0 L N x㌴hjhhU$5UjhhD5UhDhbjh5UmHnHujhhU$5U h5hjhb5hDhD5jhD5UmHnHujhhD5UjhD5U hD5hjh5U(N b d f p r t BDFx|~Ŀ̥Ĉ|tĒlh]lOljhUmHnHujXhU$UhjhUhjhj5 hb5 hj5>*hjhb5>*hbjhj5UmHnHujhhj5Ujhj5U h5hjhb5 hj5jhD5UmHnHujhD5UjphhD5U hD5 FHxl B D !""###`gdbgdb^gd & F0`0gdb$a$gdb  $gdb & F  $0`0gdb  $gdbhjln     0 2 4 > @ B D !!!!""""""">"@"#####z h5jh5U hh+qhb h_V5jhU$U hTP5 hj5>*hjhb5>*jBhU$UU h:(phjhUmHnHujhU$UhjhU hb5hjhb5hb0e students.  FORMTEXT       Complete Items 4-5 if you answered YES to Questions 2 on the Annual Report. Describe the number of students, their status in the University, and the nature and scope of the duties for which they are employed.  FORMTEXT       Discuss the actions or safeguards you will take to prevent your relationship with this enterprise from affecting your responsibilities as a University employee for supervising these students.  FORMTEXT       SIGNATURES I certify that all of the ABOVE information is correct and that I will promptly update information as changes occur. ____________________________________________ _________________________ Employee Signature Date ____________________________________________ ________________________ Department Chair Date ____________________________________________ ________________________ Standing Committee on Conflicts of Interests Date and Commitment (where applicable)     Confidential Annual Conflict Assessment Form Personnel Record 10/31/14 ##########$X%^%%%%%8&<&\&^&h&j&&&v'~'''''''''''P(R(l(n(p(r(Ȧ|hd%hjhU$hh56CJaJh'jh'Uhh3hb5hbhchjhb56h3hc5 hc5 h5 hb5jh5UmHnHujh5Uj.hhU$5U*######$$^%%%%<&h&j&l&&v''''''' =gdb gdb H gdb gdb Hgdbgdb''''.(P(R(l(n(p(r(gdb 21h:pD/ =!"#$% tDText1tDText3tDText2tDText2tDText3tDText2tDText2tDText2tDText2tDText3tDText2tDText7tDText2tDText2tDText9vDText10vDText11vDText12vDText13^ 02 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH @`@ bNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List 4@4 bHeader  !4 @4 0Footer  !6o6 j0 Footer CharCJaJH@"H j Balloon TextCJOJQJ^JaJNo1N jBalloon Text CharCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] 0 LLZZZ]  N #r(  #'r( 9EK[gm|&28GSYdpv_kqmy FFFFFFFFFFFFFFFFFFF8@0(  B S  ? Text1Text2Text3Text7Text9Text10Text11Text12Text13'`n 9r } ~ \ _ ~ 33,,&[dwxx_r m} ~ ~ ,,&9[dwxx_r m} ~ ~ ! wJ^`5o(. ^`hH. pLp^p`LhH. @ @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PLP^P`LhH.! w         ' TPD8l ?A}@ZQ_Vc|^GU$j<d%bx/x~ @L @  UnknownG*Ax Times New Roman5Symbol3. *Cx Arial5. .[`)TahomaA$BCambria Math"hF*F*jj24z z 3QHX ?b*!xx  CONFIDENTIALingramnYvonne L. Halley Oh+'0Dx    $,4<CONFIDENTIALingramnNormalYvonne L. Halley2Microsoft Office Word@@,xN@,xNj՜.+,0 hp  (Ӱԭ A & T State Universityz   CONFIDENTIAL Title  "#$%&'()*+,-./012456789:<=>?@ABEFIRoot Entry FPNHData 1Table!#WordDocument 40SummaryInformation(3DocumentSummaryInformation8;MsoDataStorezNN05UHTWEWXS==2zNNItem  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q