Relationship Disclosure Form

IDAHO DEPARTMENT OF CORRECTION
Relationship Disclosure Form
Type of Disclosure
❑ Conflict of Interest ❑ Family Relation Hired ❑ Nepotism
❑ Relative or Friend in System ❑ Romantic Relationship ❑ Unprofessional Relationship
❑ Other:
Disclosing Party Information
Name: IDOC Facility: --Select--
Job Title: Supervisor's Name:
Offender or Employee Information
Name: IDOC Facility: --Select--
Offender# (if applicable): Job Title (if applicable):
Supervisor's Name (if applicable):
Describe the Relationship
In describing the relationship between you and the affected party, please answer the following questions:
(1) How long has the relationship existed? (2)What date (or approximate date)did the relationship start?
(3)What is the current status of the relationship? (4) Is the affected party in your direct chain-of-
command?
What is your analysis of the impact this relationship may have on the IDOC or your unit? If you think the
impact may be negative, what solutions do you recommend?
(Disclosing Party's Signature) Date
Supervisor/Manager Use Only
Plan of Action: Supervisor must staff the situation with a facility head, district manager, or designee and
agree on a plan of action. Keep all information regarding this situation confidential.
Describe the plan of action.
Sign and route this form to the next approval authority.
Supervisor's Signature Facility Head, District Manager, or Bureau/Division Chief's,
Designee's Signature (if applicable) Director's, or Designee's
Signature(as applicable)
(Appendix last updated 5/13/11 ) Original: Personnel File-HRS