Conflict, independence and referral record

Illustrative specimen or blank worksheet. Not a signed contract, legal opinion, client case or evidence that Dyasol has performed these operations. Complete and agree the relevant terms before use.

Assessment scope
Engagement [ ]; entity [ ]; service [ ]; proposed functions [ ]; reviewer [ ]; date [ ]. Record whether the activity is advisory work, implementation, control-function support, independent assurance or another specialist function. A job title alone does not establish independence.

Relationships and decision authority
Identify provider/client financial interests, prior work, family/business relationships, paid or reciprocal referral, other client duties and conflicting decisions. Record relationship [ ], relevant task [ ], disclosure recipient/date [ ], client acknowledgement [ ]. Record who decides processing purposes/means, accepts risk, implements controls and independently reviews the result.

Conflict assessment and treatment
Issue [ ]; applicable legal/standard/contract condition [ ]; evidence [ ]; independence risk [ ]; separation or safeguard [ ]; remaining conflict [ ]; decision: accept limited scope / separate specialist / decline [ ]; authorised approver [ ]. Do not assume disclosure alone cures an impermissible conflict, or that reviewing one’s fix replaces independent assurance.

Review triggers
Recheck when scope, role, provider, referral arrangement or decision authority changes. Record next review [ ], owner [ ], and change history [ ]. Blank fields mean unassessed, not “no conflict”.