Holistic Healthcare
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REP-50-Conflict of Interest Report Register

Conflict of Interest Report Form

Part A – Report, Part B – Immediate Actions, and Part C – Investigation & Resolution.

PART A – REPORT

(To be completed by the person reporting the actual, perceived or potential conflict of interest.)

Conflict of Interest Details

Field Details
Full Name  
Date of Birth DD / MM / YYYY
Contact Number  
Who is reporting? ☐ Worker    ☐ Participant    ☐ Participant’s family member    ☐ Other: _________________________

Witness Details (if applicable)

Witness 1 Name Phone Address
     
Witness 2 Name Phone Address
     
Field Details
Date of Identification DD / MM / YYYY
Date of Report DD / MM / YYYY

Description of Conflict

Describe the circumstances which may give rise to an actual, perceived or potential conflict of interest:

Description of Conflict of Interest  

PART B – IMMEDIATE ACTIONS

(To be completed by the organisation’s supervisor/manager.)

Question Response
Does this conflict of interest require notifying other parties (e.g., family/guardian)? ☐ Yes       ☐ No
Date of notification (if applicable) DD / MM / YYYY
Does this conflict of interest require notifying the police (e.g., suspected crime)? ☐ Yes       ☐ No
Date of notification (if applicable) DD / MM / YYYY

Immediate Action to be Completed by Staff and/or Manager/Supervisor

Immediate Action(s) Taken  
Details of Action Taken  
Details of Action Taken  

Sign Off – Supervisor/Manager

Field Details
Full Name  
Position Title  
Signature  
Date DD / MM / YYYY

PART C – INVESTIGATION (IF REQUIRED)

(To be completed by the Clements Johnstone or their delegate.)

Details of Findings

Details of Investigation Findings  

Sign Off – Investigator

Field Details
Full Name  
Position Title  
Signature  
Date DD / MM / YYYY

Resolution / Management Action

The following actions are proposed to resolve or manage this conflict of interest:

Action Responsible Person (Full Name & Position Title) Deadline (DD / MM / YYYY)
     
     

Acknowledgement

I acknowledge that the above action has been agreed/directed to resolve the conflict of interest effectively.

Field Details
Full Name  
Signature  
Date DD / MM / YYYY
Field Details
Full Name  
Signature  
Date DD / MM / YYYY