ࡱ> Q (bjbj ;^eiei;U=*********8*b+L*+L++,,-0n1hrkF$T *2--"22:*:*,,$88882X:*,:*8,r82r88jler* l,yFv"3i2lr\<Bi"3"d l lX"*xl1"182$2111J61112222"111111111X (: Declaration of Interest and Confidentiality [Procurement Template Form Declaration of Interest and Confidentiality. This form is intended for use by evaluation panel members and other persons involved throughout a procurement process.] Conflicts of interest arise where there is a conflict between the performance of a public duty and private or personal interests and may involve personal financial or political interests. Its important to remember that conflicts of interest may be actual, perceived or potential. HYPERLINK "/government/multi-step-guides/western-australian-procurement-rules/section-b-act-ethically-integrity-and-accountability"Western Australian Procurement Rule B2 requires that officers involved in, or connected to, a procurement activity must declare any conflict of interest (whether actual, potential or perceived) they have in relation to that procurement activity, to their State agency and to the officer leading the procurement activity. To assist with compliance with rule B2, this Declaration of Interest and Confidentiality form should, prior to the commencement of a procurement process, be completed and signed by anyone who will be involved in the procurement process. Anyone who becomes involved after the commencement of the procurement process should also complete and sign a form. Once signed, provide the form to the nominated procurement process facilitator so a record can be put on the procurement file. Any conflicts of interest should also be immediately declared by the officer with the conflict, via their State agencys own conflict of interest declaration channels. Rule B2 also requires the declaring officer to take all reasonable and necessary steps to manage the conflict as soon as it is known, following their State agencys conflict of interest procedures. A record of the strategies and actions to manage the conflict should be put on the procurement file by the nominated procurement process facilitator. There are conflict of interest guidelines available from the Integrity Coordinating Group webpage at  HYPERLINK "/government/document-collections/integrity-coordinating-group" www.wa.gov.au/government/document-collections/integrity-coordinating-group. As per point 2 of the form, any change of circumstance that affects the declaration made by a person, must be advised as soon as practicable after they become aware of the change. As a minimum, declarations will be required to be made or reaffirmed, in writing, prior to the commencement of an evaluation process. For guidance to assist with fulfilling your obligations under the HYPERLINK "/government/multi-step-guides/western-australian-procurement-rules"Western Australian Procurement Rules, please see the Act Ethically with Integrity and Accountability Guideline at HYPERLINK "/government/multi-step-guides/procurement-guidelines/procurement-planning-guidelines/act-ethically-integrity-and-accountability-guideline"/government/multi-step-guides/procurement-guidelines/procurement-planning-guidelines/act-ethically-integrity-and-accountability-guideline. Declaration of Interest and Confidentiality Request Number (if known):Request Title:I (full name) of (organisation details) (Declaration of Interest) Declare that neither I nor any of my immediate family have any interests, pecuniary or otherwise, other than that mentioned below or described in the attached sheet(s), which could reasonably be construed as having any influence on the proper and objective performance by me of my duties in relation to the above specified Request. Note: Interests to be declared include but are not limited to: affiliations; conference funding; equipment donations; financial assistance; travel assistance; rebates; hospitality; relationships; shares; company ownership; training and development; consultancy services; gifts; and/or sponsorships. Declared Interest: Additional Information attached? Yes / No (Please circle and initial as applicable) Agree to truthfully declare, in writing to the Accountable Authority or delegate, any changes which may occur that relate to the matters stated in clause 1 of this Declaration, as soon as practicable after I become aware of the same; (Declaration of Confidentiality) Agree to keep all information and documents relating to the Request planning, development or evaluation process confidential, and not to disclose or communicate the same to any person or persons except in the course of my duties without the prior written approval of [Insert the name of the State Agency]; Agree not to make copies of, or take any extracts of information except as may be necessary and essential for the due and proper performance of my duties; [Include this clause if representatives external to the Western Australian State Public Service are to be involved in the procurement activity] Agree to comply with all processes and protocols established by the [Insert the name of the State Agency] from time to time to maintain the confidentiality of information and documentation relating to this project. The processes and protocols will include those for the security of documentation, communications between the [Insert the name of the State Agency] (and its officers, employees and consultants/contractors) and other parties; Agree to return all documents, papers and other materials (including the evaluation handbook) given to me relating to this project to the nominated procurement facilitator immediately when requested to do so; and Acknowledge that conflicts of interests, breach of confidentiality and unauthorised disclosure are subject to the provisions and penalties contained in the Public Sector Management Act 1994 and The Criminal Code. Unlawful disclosure of official information is a criminal offence punishable by up to three years imprisonment. [A declaration may be made using this form without the declarants signature being witnessed or counter-signed, but requiring another person to act as a witness or counter signatory provides additional assurance from a governance perspective. For guidance on executing documents electronically, the State Solicitors Office has distributed a guidance note to all agencies which contains useful contextual information.] This declaration is made by me on the understanding that I will not be taken to have breached its terms if I am legally required to disclose the information referred to. Signed By: ................................................................................................... Declarant SignatureDated  [Include this witness block if the declaration above will be witnessed by another person. It is recommended that wet signatures are witnessed, in person or via audio-visual link, where practical. Delete if not applicable.] Witnessed By: ................................................................................................... Witness Signature .................................................................................................. Witness Name and Title (Printed)Dated  [Include the counter signatory block below if the declaration is to be counter-signed by the panel chair or facilitator. Please note that electronic signatures are generally not able to be witnessed, but may be countersigned. If this form is to be signed electronically, it is recommended the electronic signatures are applied using secure digital signature technology. Delete if not applicable.] I acknowledge the declaration made above, in my capacity as [describe role, e.g. Request [No.] Evaluation Panel Chairperson]. Countersigned By: ................................................................................................... Signature .................................................................................................. Name and Title (Printed)Dated   Conflict of interest guidelines available from the  HYPERLINK "/government/document-collections/integrity-coordinating-group" Integrity Coordinating Group.  Immediate family members are spouses, de factos, children, parents, brothers and sisters.     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