Manual exhibit 5-22.3-B
INDIAN HEALTH SERVICE
CONFLICT-OF-INTEREST ANALYSIS
GIFT ACCEPTANCE
The Indian Health Service (IHS) must determine whether its interest in accepting a gift (conditional or unconditional) outweighs any concern that acceptance of the gift would reflect unfavorably upon the ability of the IHS or any employee to carry out responsibilities or official duties in a fair and objective manner or would compromise the integrity of, or the appearance of the integrity of, the IHS or of any IHS officials. Completion of this analysis is required and will become part of the annual IHS Gift Acceptance report. All responses answered unfavorably should be given considerable scrutiny.
Gift Offer:___________________________
______________________________________________________________________________________
Donor Name
Address
| 1. | Does the IHS have an interest in accepting the Gift? YES_______ NO_______ |
| 2. | Will this gift enhance or enable the IHS's ability to
accomplish its mission and/or goals? YES_______ NO_______ |
| 3. | Is the donor an acceptable source? YES_______
NO_______ |
| 4. | Does the Gift meet generally acceptable public standards?
YES_______ NO_______ |
| 5. | Is the gift reasonable to administer? YES_______
NO_______ |
| 6. | Will the principal beneficiary of hte gift be the IHS?
YES_______ NO_______ |
| 7. | Does the IHS control activity in which the donor has an
interest or the potential for an interest? If so, what are the
activities? (Example: potential or current contractor.)
YES_______ NO_______ ____________________________________________________________________________ |
| 8. | Will acceptance of the gift compromise the integrity of, or the appearance of the integrity of, an IHS program or of any official involved in that program?
YES_______ NO_______ |
| 9. | Is there an actual or apparent conflict of interest?
YES_______ NO_______
____________________________________________________________________________ |
| 10. | Was the gift solicited by an IHS employee? YES_______
NO_______ |
| 11. | Will the size or the nature of the gift raise a significant
concern? YES_______ NO_______ |
| 12. | Is the gift offered to support the activities of an
individual employee? (If yes, please explain.) YES_______
NO_______
____________________________________________________________________________ |
| 13. | Will accepting the gift reflect unfavorably on the ability
of the IHS or any employee to carry out responsibilities or official duties
in a fair and objective manner? YES_______ NO_______ |
| 14. | Is the gift being offered for endorsement purposes?
YES_______ NO_______ |
| 15. | Are there donor-imposed restrictions or conditions?
(If yes, please explain.) YES_______ NO_______
____________________________________________________________________________ |
| 16. | Is there sensitivity of any matter pending before the IHS
that would affect the interest of the donor? (Please explain.)
YES_______ NO_______
____________________________________________________________________________ |
| 17. | Are there any affects of accepting the gift on entities
that are inside/outside the IHS? For example, would any identifiable
class, persons, or entities be benefitted or disadvantages by the acceptance
of the gift by the IHS? (If yes, please explain.) YES_______
NO_______
____________________________________________________________________________ |
| 18. | has the Office of the General Counsel (OGC) or Program
Integrity and Ethics Staff (PIES) been consulted to provide guidance on
problematic issues about acceptance of the gift? (If yes, please
explain.) YES_______ NO_______
____________________________________________________________________________ |
| 19. | What is the practical impact of the gift in the IHS
mission? COMMENTS:________________________________________________________________
____________________________________________________________________________ |
| 20. | Why is the gift being offered to the IHS? COMMENTS:________________________________________________________________ ____________________________________________________________________________
|
If your answer is " NO to any of questions 1 through 6, or "YES" to any of questions 7 through 18, then careful scrutiny should be given to any unfavorable responses, and the OGC and/or PIES should be consulted as a precautionary measure.
COMMENTS:________________________________________________________________
____________________________________________________________________________
SIGNATURE PAGE
Gift Offer:__________________________________
______________________________________________________________________________________
Donor Name
Address
______________________________________________________________________________________
Gift
Reviewing/Recommending Official:
______________________________________________________________________________________
ACCEPT
DO NOT ACCEPT
______________________________________________________________________________________
Signature: Name
Title
Date
Executive Officer:
______________________________________________________________________________________
ACCEPT
DO NOT ACCEPT
______________________________________________________________________________________
Signature: Name
Title
Date
Authorizing Official:
______________________________________________________________________________________
ACCEPT
DO NOT ACCEPT
______________________________________________________________________________________
Signature: Name
Title
Date