Child Support Program Case
Section 1 (To be completed by employee)
Name of Employee: / Employee RACF:
DHS Branch Location:
DHS Case Number:
Child Support Program (CSP) Case Number:
Name of Party:
Employee’s Relationship to Party:
Have you accessed this party’s file? / Yes / No
If yes, please explain:
Section 2 (To be completed by employee)
I understand that unless I am notified by my managers that a conflict of interest does not exist, I may not access the Child Support Program (CSP)case file of the above named party for any reason and under no circumstances may I disclose confidential CSP case information to that party.
Employee’s Full Name (printed):
Employee’s Signature: / Date:
Section 3 (To be completed by manager)
A. / I have reviewed the above file and have determined that a conflict or potential conflict does not exist.
B. / I have reviewed the above file and have determined that a conflict or potential conflict does exist, but reassignment of the DHS case to another DHS branch is not necessary. The employee is prohibited from accessing the Child Support Program (SCP) case or CSP case information.
C. / I have reviewed the above file and have determined that a conflict or potential conflict does exist and the DHS case has been reassigned as set out below. The employee is prohibited from accessing the CSP case or CSP case information.
New Assigned DHS Branch Office:
New DHS branch/office notified / Paper file transferred
Employee notified of determination/branch
Section 4 (To be completed by manager)
If I have determined that a conflict does not exist and marked A. above. I will send this completed conflict of interest form to:
DHS Office of Human Resources
Section 5 (To be completed by manager)
If I have determined that a conflict does exist and marked B. or C. above, I will send this completed conflict of interest form to:
DHS Office of Human Resources
AND to one of the following:
For APD, send to
For SSP, send to
Section 6 (To be completed by manager)
Manager’s Full Name (printed):
Manager’s Signature: / Date:
Use Page: DHS 0429 (Notice of Conflict of Interest with a Child Support Program Case)
Section 1 (To be completed by the employee with a potential conflict of interest.)
“DHS Branch Location” is the branch where the employee with the potential conflict and the DHS case linked to the CSP case in question is located.
“DHS Case Number” is the number of the DHS case that is linked to the child support case in question. (Note: When an employee is reporting their own child support case as a conflict of interest, the DHS case number may not be applicable.)
“Child Support Program (CSP) Case Number” is the number of the CSP case with which the employee is reporting a potential conflict of interest. (Note: If the employee does not know the CSP number, the employee should leave this space blank.)
“Name of Party” is the name of the person on the child support case that the employee knows. When reporting one’s own child support case, “self” should be listed in this space.
“Employee’s Relationship to Party” is a description of how the DHS employee knows the party. This may include friend, relative, acquaintance, self, etc.
Indicate “yes” the employee has accessed this party’s file or “no” the employee has not. If the file has been accessed, explain in the space provided.
Section 2 (To be completed by the employee with a potential conflict of interest.)
Print name. Sign name. Date form.
Section 3 (To be completed by the manager of the employee with a potential conflict of interest.)
Mark Box A when the manager determines a conflict of interest does not exist.
Mark Box B when the manager determines a conflict of interest does exist but the DHS case linked to the CSP case with which the employee has a conflict does not need to be reassigned to a new DHS branch office.
Mark Box C when the manager determines a conflict of interest does exist and the DHS case linked to the CSP case with which the employee has a conflict does need to be reassigned to a new DHS branch office. Indicate the new assigned DHS branch office. Mark one or more of the appropriate three boxes in this section.
Section 4: (To be completed by the manager of the employee with a potential conflict of interest.)
If the manager determines a conflict of interest does not exist, mark the appropriate box and send a copy of this form to the DHS Office of Human Resources.
Section 5:(To be completed by the manager of the employee with a potential conflict of interest.)
If the manager determines a conflict of interest does exist, mark the appropriate boxes and send one copy of the form to the DHS Office of Human Resources and one copy to the APD or SSP contact, whichever is appropriate.
Section 6 (To be completed by the manager of the employee with a potential conflict of interest.)
Print name. Sign name. Date form.
DHS 0429 (3/16)