Bridgewater State University
State Ethics Commission Disclosure Form
 

Date:

 

To:             Dana Mohler-Faria, President, Bridgewater State University

 

From:          Professor _______________,  ___________Department

 

Re:              Disclosure of Decision to Adopt Instructional Materials In Whose Sale I Have a Financial Interest

 

In compliance with the Massachusetts G.L.c.268A, §6, I disclose my intent to adopt the following:

 

Semester:                 Year:                       (  ) Day    (   ) DGCE   (   ) Non-Credit  check all that apply

Course Number and Title:

Anticipated course enrollment:  _______students in ___________sections.                                          

Full description of materials (e.g., published text, course-pack, CD, etc)  (use reverse side of form if necessary)

 

 

If this is a published work sold to students through a 3rd party such as a bookstore:

Check all that apply

(  ) I am the author        (   ) I am the editor        (  ) Other (indicate)

(   ) I am the co-author  (   ) I am the co-editor

From sale of this title to Bridgewater State University students I anticipate that I will receive royalties in the amount of $______________.

 

If you are the publisher of this work and are selling it directly to students:

 

From direct sale of this title to Bridgewater State University students I anticipate that I will receive income of $_______________  of which $______________ is profit.

 

 

In the event you determine that my financial interest is sufficiently substantial to warrant assigning to someone else the decision whether the instructional materials described above should be adopted for use in the course identified above, I agree to allow the Department Chair/Graduate Program Coordinator to make that decision in my stead. 

 

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Signature of Faculty Member        Date

__________________________________________________________________________________________________________

Determination of Bridgewater State College Appointing Authority

(  ) I have reviewed this matter and determine that the faculty member’s financial interest as disclosed above is not sufficiently substantial to warrant my assigning to someone else the decision whether the instructional materials described above should be adopted for use in the course identified above.

                       

(  ) I have reviewed this matter and determine that the faculty member’s financial interest is sufficiently substantial to warrant my assigning the decision in question to someone else. Therefore, in accordance with M.G.L.c.268A, §6, I assign that decision to the Department Chair/Graduate Program Coordinator.

 

 

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Dana Mohler-Faria, President              Date