Attachment 1 - Conflict of Interest.pdf

This is a Sample Conflict of Interest Acknowledgment form from the Veterans Health Administration (VHA) Handbook 1660.03, dated November 4, 2015, serving as Appendix A.

The form is a template designed for completion by Chiefs of Staff, physicians, clinicians, researchers, allied health supervisors or managers, and any individuals who assume HCR (Health Care Related) contract duties or VA employees participating in HCR Contracts. Signatories acknowledge receipt and agreement to abide by VHA Handbook 1660.03 guidance regarding conflicts of interest in contracts or agreements involving the sharing of HCR. The form requires individuals to confirm they have received appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position and directs them to the VHA MSO Customer Resource Center for additional information. Signatories further acknowledge that the completed acknowledgment may be placed in their Electronic Official Personnel File and that a copy will be retained in the official procurement file of any HCR Contracts in which they are involved. The form includes spaces for signature and date completion and is not a substantive contracting document but rather a compliance and acknowledgment tool.