Ref. No.

RGF-COR-MD-21-01
Rev. No. 01
Rev. Date 01.01.2019
Applicable
QA/QC, All Dept. & Labs.
CONFLICT OF INTEREST QUESTIONERS for
ISO 9001:2015 & ISO/IEC 17025:2017 Used By Please write lab name

No. Description/Questions Answer

Are you or is any member of your immediate family a director, officer, owner, partner, Yes No
employee, an independent contractor of, an agent of, or a consultant to any firm to
whom RGF provides any kind of services?

1. If yes, identify the name of the business and describe the business and the nature of your relationship to
it and that of your immediate family.

Details :

In the past twelve months, have you or has any member of your immediate family had Yes No
a direct or indirect financial interest in any business, to whom RGF provides any kind
of services?
If yes, identify the name of the business and describe the business and the nature of your relationship to
2. it and that of your immediate family.
Details :

At any time in the past twelve months, have you or has anyone from your immediate Yes No
family received any gift (other than promotional items or an occasional meal) or
unusual hospitality from the client to whom RGF provide all kind of service?
3. If yes, note face value of gift or details of unusual hospitality:
Details :

Are there any other personal activities of yours, not reported under the previous Yes No
questions, that you think might be a conflict of interest with respect to your work at
RGF?
4. If yes, describe here the nature of the activity.
Details :

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 Ref. No. RGF-COR-MD-21-01
Rev. No. 01
Rev. Date 01.01.2019
Applicable
QA/QC, All Dept. & Labs.
CONFLICT OF INTEREST QUESTIONERS for
ISO 9001:2015 & ISO/IEC 17025:2017 Used By Please write lab name

No. Description/Questions Answer

Do you have occasion to use RGF resources (equipment, space, supplies or your paid Yes No
work time other than incidental interruption) in performing paid or volunteer activity
for entities other than RGF?
5. If yes, describe here the activity, resources, and number of hours per week of RGF time used.
Details :

Did or do you or has any member of your immediate family plan to establish or Yes No
continue a financial or other relationship with any person or company which
transacted or sought to transact business with RGF or which actually or potentially
competed with RGF?
6. If yes, please indicate whether you participated in such transaction, negotiation, or competing business
activity on behalf of either party.
Details :

Employee : Approved By :

Name Name

Position Title

Branch/Dept. Branch/Dept.

Signature Signature

Date Date

2 of 2