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Effective Date: 




Updated: 7/2007



Access and Intake Regional and Local Services staff complete this form to notify the first-line supervisor of any relationships that may lead to a potential conflict of interest or the lack of such relationships. Form 2115 should not be confused with Form HR0302, Request for Clearance for Non-Agency Employment or Activity.



When to Prepare

Prepare this form upon hire, annually and also for employee or supervisor transfers. Staff complete this form when a relationship exists between Texas Health and Human Services Commission (HHSC) staff and a provider, provider employee, applicant, individual, relative or individual living in the same house, dating companion, supervisor or someone under HHSC staff supervision that could result in or give the appearance of a conflict of interest. Staff must report the relationship even if the staff person is not involved in the eligibility determination for the applicant or individual. Staff also complete the form to report that no conflict of interest exists.

Number of Copies

Complete an original.


Send the original to your first-line supervisor.

Form Retention

File forms in personnel files for the staff who originated the form and retain according to the retention requirements for personnel files. If staff identified a potential conflict of interest relationship with an applicant or individual and the first-line supervisor completed the supervisory review, the case manager must retain a copy of the completed form in the case record according to the retention requirements of the case record.


Detailed Instructions

Staff Name — Enter the name of the person completing this form.

Supervisor Name — Enter the name of your first-line supervisor.

Identification of individual/entity with whom a potential conflict exists — Check the appropriate box to indicate whether the potential conflict involves provider or provider employee, individual or applicant, or another individual or entity. Enter the name of the individual/entity involved.

Nature of the potential conflict: — Provide only information that is necessary to describe the potential conflict.

No conflict of interest exists. — Check this box to indicate that there is no relationship with a provider or provider employee, individual or applicant, or another individual or entity that may be considered a conflict of interest.

Supervisory Review — The first-line supervisor will record the action that may be necessary and forward the form to the second-line supervisor for review and approval. The first-line supervisor does not need to complete the supervisory review if staff indicated that there is no conflict of interest.

Upon form approval:

  • the first-line supervisor reviews the supervisory review with staff;
  • a copy of the completed form will be retained in the case record if Form 2115 is initiated by the case manager and the relationship in question is with an applicant or individual; and
  • the completed form will be retained in the personnel file for all HHSC staff.