Gifts and Benefits Disclosure Form – Sunnyside Australia Forms

This form is used to disclose any gifts, benefits, or other forms of hospitality received or offered that may present an actual or perceived conflict of interest in connection with the provision of NDIS services. All disclosures will be reviewed in accordance with our conflict of interest and ethics policies.

Employee Details

Full name:

Position Title:

Details of Gift/Benefit Offered/Received

Name and/or Organisation of the Giver/ Recipient:

Nature of the Gift/Benefit: (e.g., monetary gift, voucher, complimentary service, hospitality, discount, etc.)

Description: Provide details regarding the gift or benefit (e.g., items provided, nature of service, specific circumstances):

Estimated Value:

Date Gift/Benefit was Offered/Received:

Circumstances and Purpose: Briefly explain the context in which the gift/benefit was offered/received and any associated conditions or expectations:

Conflict of Interest Declaration

Please indicate whether you believe this gift/benefit may create, or be perceived to create, a conflict of interest with your role or duties as a representative of Sunnyside Australia:

yes

If “Yes,” please provide further details

Action and Management

Has this gift/benefit been approved by your Leader?

yes

If yes, please provide the name and title of the Leader:

What action is recommended to manage or mitigate any potential conflict? (e.g., return the gift, record the gift, disclose the benefit to affected parties, etc.)

Acknowledgement

I hereby declare that the information provided above is accurate and complete to the best of my knowledge. I understand that failure to disclose any gifts or benefits may result in disciplinary action and that all disclosures will be used to ensure transparency and integrity in our service delivery.

Name:

Signature:

Clear