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Instructor Disclosure Form

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INSTRUCTOR DISCLOSURE FORM

Purpose: This form collects information necessary for institutional compliance, conflict-of-interest assessment, intellectual property management, and maintenance of accurate personnel records. The instructor must disclose all relevant professional activities, financial interests, outside employment, and relationships that may reasonably be perceived to affect instructional responsibilities, research, or student interactions.

Instructor Information

Instructor Name:

Employee ID:    Title/Rank:

Hire Date:    Campus/Unit Location:

Employment Status






Credentials and Certifications

Issuing Institution:    Year Awarded:

Conflicts of Interest and External Activities

The instructor must disclose financial interests, outside employment, consultancies, equity holdings, paid speaking engagements, or other activities that could present an actual, potential, or perceived conflict of interest with institutional duties. Disclose each relationship below.






Sponsored Research and Funding

Do you currently receive external research or instructional funding, grants, or contracts administered through the institution?        

Financial Interests in Educational Materials and Vendors

Do you receive royalties, licensing fees, or other payments from publishers, educational vendors, or software providers related to instructional materials?        

Teaching, Supervision, and Student Relationships

Do you have a familial, financial, or intimate relationship with any student currently enrolled in your courses or under your supervision?        

Intellectual Property and Course Materials

Indicate whether course materials you develop are subject to separate institutional agreements or external licensing arrangements.

Certification and Acknowledgment

By signing below, I certify that the foregoing information is true, complete, and accurate to the best of my knowledge. I agree to update this disclosure within 30 days of any material change in the information provided. I acknowledge that failure to disclose relevant activities, financial interests, or relationships may result in administrative review and disciplinary action in accordance with institutional policy. I authorize the institution to review supporting documentation and to share disclosure information with appropriate institutional officials for compliance review, contract review, and conflict management.

I further certify that I have read and understand my obligations with respect to conflicts of interest, sponsored research reporting, and ownership or licensing of intellectual property arising from my activities associated with the institution.

Printed Name:

Signature:

Date:

Submission of this form constitutes an attestation that the information above is true and that the signer understands institutional reporting obligations and potential consequences for false or incomplete disclosures.

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What the Instructor Disclosure Form Is

The Instructor Disclosure Form is a written statement completed by an instructor to disclose matters that may be relevant to their role, such as conflicts of interest, outside employment, paid speaking or consulting engagements, professional qualifications, and relevant background checks. Institutions use the form to document transparency, manage compliance with institutional policies, and assess any potential impact on course content, student safety, or accreditation. This document often becomes part of personnel or compliance records and supports consistent review by departments or compliance officers.

Why this form matters for institutions and instructors

An Instructor Disclosure Form helps institutions identify potential conflicts, meet regulatory or accreditation expectations, and maintain academic integrity while giving instructors a standard method to report relevant activities. Completed forms create an auditable record that supports policy enforcement and risk management under applicable U.S. electronic signature rules such as ESIGN and state UETA statutes.

Why this form matters for institutions and instructors

Who completes and reviews Instructor Disclosure Forms

The form is completed by instructors and reviewed by administrative staff responsible for compliance, human resources, or academic affairs.

  • Adjunct and full-time instructors who teach or supervise students
  • Department chairs and program directors managing academic oversight
  • HR and compliance officers maintaining personnel records

Clear routing and defined reviewer roles reduce delays and ensure consistent handling of disclosures across the institution.

Core elements to include in a professional disclosure form

A complete Instructor Disclosure Form groups key information into clear sections so reviewers can assess risks quickly and consistently.

Identification

Instructor name, employer or department, job title, and employee or contractor ID to match personnel records and payroll.

Affiliations

List outside employers, board memberships, affiliations, or paid consultancies that might create perceived or actual conflicts of interest.

Financial Interests

Disclose relevant financial stakes such as equity, royalties, paid speaking, or sponsored research that relate to teaching duties.

Prior Convictions

Report criminal convictions or pending charges if required by institutional policy, with explanation and dates as applicable.

Certifications & Licenses

Provide professional licenses or certifications relevant to the instructor role and attach supporting documentation where required.

Acknowledgements

Signature block, date, and affirmation that the information is complete and that the instructor will update the form promptly if circumstances change.

Required fields and data elements

Full Legal Name: Enter name as on government ID.
Title and Department: Provide official job title and home department.
Contact Information: Work email and phone for verification.
Disclosure Details: Concise description of the activity.
Effective Date: Use MM/DD/YYYY.
Signature Line: Typed or handwritten signature plus date.

How to complete the Instructor Disclosure Form

Follow a short, consistent sequence to complete and submit the form so reviewers receive accurate, comparable disclosures across departments.

  • 01
    Gather documents: Collect IDs, licenses, and contract information before starting.
  • 02
    Fill fields: Enter required fields exactly; use MM/DD/YYYY for dates.
  • 03
    Attach evidence: Upload licenses, contracts, or conflict details as PDFs.
  • 04
    Sign and submit: Sign, date, and route to the designated reviewer email or system.

Customizing the online workflow for disclosures

Configure an online workflow to route forms automatically, require attachments, and notify reviewers to shorten turnaround and create a complete audit trail.

Field Configuration
Required Fields Make name, effective date, and signature mandatory
Attachments Require supporting files for licenses or contracts
Routing Auto-route to department chair then HR
Notifications Email alerts for pending and completed reviews

Typical submission and review process

A standard process reduces ambiguity: submit, route, review, and archive, with automated checks for missing information.

  • Submit: Instructor completes form and attaches documents.
  • Initial Review: Department reviewer checks for conflicts and completeness.
  • Escalation: Complex disclosures route to compliance or legal.
  • Archive: Signed record stored in personnel file or records system.

Distribution and e-submission considerations

Choose a delivery method that preserves the record, provides signer attribution, and meets any applicable privacy rules.

  • Email links: Simple delivery; relies on email authentication.
  • Secure portal: Provides access control and audit logs.
  • In-person: Used when physical ID or notarization is required.

Ensure whatever channel you use supports retention, audit trails, and the level of signer authentication your policy requires.

Timing: when to submit and update disclosures

Set clear deadlines for initial disclosure, periodic update, and post-change reporting so records remain current and reviewers can act on new information.

Initial Submission:

Before the first teaching assignment or on hire.

Annual Update:

Submit yearly or at the institution's specified interval.

Change Reporting:

Report new conflicts within 30 days of change.

Review Cycle:

Department completes review within 14 business days.

Record Closure:

Finalized and archived after review concludes.

Common errors to avoid when preparing the form

  • Entering informal or partial names that do not match personnel records or tax documents, which causes verification delays.
  • Failing to attach required supporting documents such as licenses or contracts, leaving reviewers unable to verify disclosed items.
  • Using ambiguous language like 'may receive compensation' instead of providing amounts or role descriptions required by policy.
  • Skipping the signature or dating field, which can render the disclosure incomplete and prevent processing.

Risks and potential consequences of incorrect disclosures

Employment Action: Disciplinary or termination risk
Funding Loss: Grant or contract jeopardized
Reputational Harm: Negative institutional publicity
Privacy Breach: Exposes PII if mishandled
HIPAA Exposure: Healthcare disclosures may trigger HIPAA issues
FERPA Risk: Student-record implications for education contexts

Pricing comparison for common e-signature platforms

Basic price and feature differences frequently affect tool selection for form distribution and signing; signNow is listed first for direct comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Practical examples of disclosure use

These scenarios illustrate common disclosure needs and how forms support consistent decisions and recordkeeping.

University Adjunct Disclosure

An adjunct lists outside consulting with a textbook publisher

  • Reviewer notes potential academic bias
  • Department requires mitigation steps and archives the signed disclosure in the HR file for three years.

Clinical Instructor Disclosure

A clinical instructor discloses paid speaking for a device manufacturer

  • Compliance flags a financial interest
  • Institution documents conditional permissions and retains approvals per HIPAA and institutional policy.

Typical signatories and approvers

Department Chair

Department chairs review disclosures for conflicts affecting course assignments and research. They document decisions and recommend mitigation, forwarding complex cases to compliance or legal.

Instructor

The instructor certifies the accuracy of disclosed information, signs and dates the form, and is responsible for timely updates when circumstances change.

Key milestones in the disclosure lifecycle

Track milestones from initial submission through review and archival so obligations and timelines are clear to all parties.

01

Draft Completed

Instructor completes the form and attaches evidence.

02

Submission Date

Form is submitted to department for initial review.

03

Review Decision

Department renders mitigation or approval decision.

04

Archival

Signed form stored in records and retention schedule applied.

FAQs about the Instructor Disclosure Form

Answers to common questions about completion, e-signing, notarization, and recordkeeping to help instructors and administrators avoid delays.


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