Regional Orientation Onboarding Form "*" indicates required fields General InformationName* First Last Program / Department* Site / Facility* EFT* Conflict of Interest InformationPlease review our GA-01-P-050 Conflict of Interest policy at the top of this page.Consent* I have read and agree to the Conflict of Interest Policy GuidelinesPOLICY Conflict of Interest Guidelines apply to all persons (individual or corporate) associated with the Interlake-Eastern RHA whether employed, volunteer, contract or fee-for-service. For the purposes of this policy, the term ‘employee’ shall refer to all these persons. Conflict of Interest shall be defined as any situation in which an employee has a private or personal interest that could appear to influence the objective exercise of their official duties. A conflict of interest is a divergence between the employee’s and/or their family’s personal, financial or business interests and the employee’s professional obligation to exercise their official duties such that an independent observer might reasonably question whether that employee’s actions, decisions or undertakings are influenced by personal gain – financial or otherwise. Family includes spouse, common-law spouse, child, parent, sibling, grandparent, in-law, grandchild, former guardian, boyfriend, girlfriend, and business partner/associate. Personal gain refers to any service or item that benefits an employee or their family (e.g. all forms of gifts, gratuities, favours, tickets, meals, discounts, preferential treatment, etc.). Employees shall perform their duties in a manner that does not place them in a conflict of interest. Additionally, employees shall make every effort to avoid any and all situations that place them in an apparent, potential or perceived conflict of interest. PROCEDURE 1.1 At all times, employees shall: 1.1.1 Maintain the highest standard of integrity and impartiality; 1.1.2 Act in good faith with a view to the best interests of the Interlake-Eastern RHA; 1.1.3 Be aware and vigilant of the need to avoid conflict of interest situations; 1.1.4 Not use their position with the Interlake-Eastern RHA for personal gain; 1.1.5 Not solicit any personal gain regardless of value; 1.1.6 Not use resources or information related to their role with the Interlakeu0002Eastern RHA for personal gain; GA-01-P-050 Conflict of Interest Page 2 of 3 1.1.7 Not disclose any information to a third party that would place that party in a position of advantage over its competitors in relation to the business of the Interlake-Eastern RHA; 1.1.8 Absent themselves from any and all decision making or advice provision where they have a private interest. 1.2 Employees shall not accept gifts, gratuities, bequests or entertainment for their personal benefit from past or present patients, clients and their families. This does not include gifts of a personal nature that have no real monetary value (e.g. a thank you card from a patient’s family or a homemade gift from a client). 1.3 Tokens of appreciation of nominal value received from patients, clients and residents may be accepted on behalf of the department, ward or unit. 1.4 Employees shall not accept gifts, gratuities or entertainment from existing or political parties, prospective vendors or suppliers of services, products, or knowledge to the Interlake-Eastern RHA. 1.5 Solicitation of funding, prizes, give-a-ways and in-kind donations from vendors and individuals shall only be allowed in situations linked to explicit and Board approved Interlake-Eastern charitable or program-related activities and consistent with the Interlake-Eastern Corporate Relations Policy. All donors shall be informed in writing that their decision to participate will not have any influence on Interlake-Eastern RHA procurement or program planning decisions. 1.6 Employees who believe that they may be in a conflict of interest situation; or, who may wish to report an alleged conflict, must disclose the conflict to their supervisor immediately upon becoming aware of the conflict. If the supervisor is perceived to be involved in the conflict, the employee should report the conflict to another neutral management representative in the program or department. If a conflict of interest is determined by program or department management; it must be reported to the Vice President of Human Resources for review and/or investigation. 1.7 Employees are required to disclose through a Conflict of Interest declaration to the Vice President, Human Resources all of their outside relationships with Industry or External Agencies that could result in a Conflict of Interest situation and have an obligation to update and revise this declaration should there be any relevant and material changes as applicable. 1.8 Form GA-1-F-6874 Employee Declaration shall be returned as a signed original document to the Vice President, Human Resources to be kept on the employee’s personnel file. 1.9 The Vice President of Human Resources shall have oversight of the Conflict of Interest Policy and will have conduct of the investigation process regarding any conflict of interest matters. 1.10 Employees in breach of this policy will face consequences in accordance with applicable Human Resource policies including, but not limited to, progressive discipline, suspension with or without pay, or termination. 1.11 This policy shall be communicated and distributed to all employees through the employee orientation process.Having reviewed the Interlake-Eastern RHA Conflict of Interest policy:* I declare that I have no situations or associations that would place me in a potential, real or perceived Conflict of Interest, including but not limited to a financial ownership, judiciary role or receiving payment from industry in any form. I may be in a situation or association, which places me in potential perceived or real Conflict of Interest. Possible conflict of interest details are as follows:Bilingual InformationBilingual Status* I choose not to declare I am not bilingual I am bilingual Additional Bilingual InformationPlease indicate any languages, other than English, and YES or NO if you speak, read, or write that language.LanguageUnderstandSpeakReadWrite Add RemoveUse the plus or minus buttons located on the right side of each row to add or remove language informationBilingual French / English Employees OnlySelf-Declaration InformationAre you an indigenous person as defined in the Canadian Constitution I.E. First Nation, Inuit, or Metis?* Yes No I choose not to declare Select which best describes you: Status Indian Non-Status Indian Métis Inuit Declared Indigenous Person because Status Indian Registered with: Status # Nation Registerd or Affiliated with: Registered With Métis Federation Affiliated With Métis Local / Community Registration Affiliation Inuit Beneficiary / Assoc. / Inuk / Inuit Community Enrolled as a Beneficiary Labrador Inuit Association Member Affiliated Inuk / Inuit Community I declare myself to be an indigenous person because:Driver License InformationI currently have a driver's license* Yes No Driver License Number Driver license Class Do you plan to acquire a driver's license? Yes No What are your plans for acquiring a driver's license?Media ConsentConsent I agree to the below conditionsI grant consent to the Interlake-Eastern Regional Health Authority to reproduce any images or representations of me, my name title and/or location, in the whole or part, taken on the date started above in any format, whether electronic, print or otherwise, in all media, including media for publishing, advertising and public relations purposes, now and in the future. I hereby waive the right to inspect or approve the images, representations, or any captions or text that may be used in conjunction with them, the use to which the images may be applied, or to receive any compensation for the use of the image. I hereby release and forever discharge the Regional Health Authority and its officers, directors, employees, agents, and successors from any claims and liability for any damages, injuries or causes of action that I may incur as a result of the use, disclosure or retention of the images.Diplomas, Certifications Drop files here or Select files Max. file size: 10 MB. SignatureBy signing the above, I HEREBY CERTIFY that the information provided in this form is complete, true and correct to the best of my knowledge, and that I have read and understood the Conflict of Interest policy above.EmailThis field is for validation purposes and should be left unchanged.