Please note that Duke specifically seeks information about past misconduct or policy violations (in the past ten (10) years) and/or relevant pending investigations as part of the application process. Disclosures will not be an automatic bar to hiring but, instead, will initiate further dialogue regarding past actions and steps taken to address them. Disclosures will not be shared with search committees during the application review process.
Duke University is committed to the shared values of respect, trust, inclusion, discovery and
excellence. As part of this commitment, we expect all members of our community, including
faculty, to conduct themselves in a manner that is ethical, legal, and professional. These are the
ideals we must commit to uphold to earn and maintain our reputation for excellence and integrity
and for each member of the Duke community to do their part to foster a professional and respectful
research and learning environment. To that end, we ask you to respond to the following questions,
and invite you to provide additional context for any affirmative answers. Disclosures will not be
an automatic bar to hiring but, instead, will initiate further dialogue regarding past actions.
The scope of these questions includes reviews or investigations by current employers, former
employers, educational institutions, federal or state regulatory bodies, licensing boards, research
sponsors, professional organizations or any other entity in the past seven (10) years (within seven
(10) years from the date of this attestation).They also focus on policy violations or misconduct,
including but not limited to research misconduct, animal welfare or human subjects research
issues, deficient or misrepresented research proposal disclosures, conflicts of interest or
commitment, bullying, discrimination, harassment, sexual misconduct, financial fraud, misuse of
resources, retaliation, violation of a consensual relationships policy, or any other potential policy
violations. Disclosures will not be an automatic bar to hiring but, instead, will initiate further
dialogue regarding past actions and steps taken to address them. Disclosures will not be shared
with search committees during the application review process.
In the past seven (10) years:
Have you been found responsible for misconduct or for violating a policy in connection with your
employment or education? [Yes/No]
Have you resigned or otherwise left a position, program or organization while under review or
investigation for potential misconduct or a potential policy violation in connection with your
employment or education? [Yes/No]
Has a complaint of potential misconduct or a potential policy violation against you been resolved
through an institution’s or organization’s alternative dispute resolution process? [Yes/No]
Have you been formally disciplined (such as a letter of reprimand or written sanction) or had
privileges or responsibilities (such as travel privileges, advising students, or research privileges)
temporarily or permanently removed? [Yes/No]
Have you been required to attend mandatory training or coaching in response to specific
complaints raised about your conduct? [Yes/No]
Are you currently under review or investigation for potential misconduct or a potential policy
violation in connection with your employment or education? [Yes/No]
If you answered “yes” to any of the questions above, please explain:
______________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
If you are unsure whether certain information is relevant to these inquiries, please err on the side
of disclosure. Please note that complete answers to all questions above and your consent to the
release of information regarding your employment and/or educational background is required;
failure to respond fully to these questions and/or to provide such consent and release as requested
(whether by Duke and/or other relevant entities) will render your application incomplete and it
will not receive further consideration.
By signing below, you affirm that all information provided to Duke in this attestation form and in
connection with your application is accurate, complete and true and that you will promptly notify
Duke if your responses above change while your application is pending or during any employment
by Duke. Finally, you acknowledge that if it is discovered that you made false or misleading
statements or concealed information relevant to your application, this may be considered a form
misconduct resulting in rescission or withdrawal of this job offer and/or termination of any faculty
appointment.
Prior Institution’s Contact Name & Office:____________________________________________
Contact Email Address: __________________________________________________________
Contact Telephone Number: _______________________________________________________
Candidate Full Name:____________________________________________________________
Signature: ________________________________________Date:_________________________
By signing below, I authorize the organizations and/or entities identified below to share
information and documents related to me with Duke University and/or Duke University Health
System (hereinafter referred to as “Duke”) as outlined herein and as requested by Duke.
This includes but is not limited to information and documents from my personnel files, any
information related to my performance, behavior, actions or conduct, concerns raised about my
conduct or performance, investigation reports or performance reviews, reports to research sponsors
or licensing boards, and corrective or disciplinary actions. I authorize Duke to contact any
representative of or other individual (not just those named below) currently or formerly associated
with the organizations and/or entities identified below. I understand that the information released
may be highly sensitive and/or may adversely affect my application for employment with Duke.
By signing below, I knowingly and voluntarily relinquish any claim I may have against Duke and
the organizations and/or entities identified below, their current and former students, agents and
representatives, and any other individual involved in the release of any information and/or
documents as authorized herein. I agree to hold them harmless from any and all liability of every
nature and kind arising out of or pertaining to the release of this information and from any resulting
consequences from such disclosure, including but not limited to any adverse employment action.
This release shall be binding on my legal representatives, agents, and successors. I authorize
release by the following organizations and/or entities:
Please provide contact information for any University/College/Organization you have been
employed in the last 10 years.
Faculty Candidate Full Legal Name
Third-Party Organization or Entity and relationship to candidate (e.g., former employer)
Relevant Dates (if any)
Name & email address of Best
Contact (for relevant information)
I also agree to sign any additional release forms as needed to ensure full disclosure of information.
I have read this authorization form, fully understand its terms, and sign it freely, knowingly and
voluntarily:
______________________________________________ ______________________
Signature Date
By signing below, I accept this conditional offer of employment and I affirm that all information
I provided to Duke in connection with my application is accurate, complete and true at this time,
including the representations made in my signed attestation regarding past misconduct. Again, I
understand that I must promptly notify Duke if my responses on the attestation change while my
application is pending or during any employment by Duke and acknowledge that making false or
misleading statements or concealing information relevant to my application may be misconduct
resulting in rescission or withdrawal of this job offer and/or termination of any faculty
appointment.
Signature required for acceptance of offer: