Attachment 1 - Conflict of Interest.pdf

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

The form is designed to be completed by each Chief of Staff, physician, clinician, researcher, allied health supervisor or manager, and any individual who assumes duties or participates in Healthcare Related (HCR) Contracts. The acknowledgment requires signatories to confirm they have received, read, and agree to abide by the guidance contained in VHA Handbook 1660.03 regarding conflicts of interest in contracts or agreements for sharing of HCR. Signatories must also acknowledge that they have completed the appropriate Tier Level Medical Sharing/Affiliate Office Customer training and understand that the acknowledgment may be placed in their Electronic Official Personnel File and a copy will be placed in the official procurement file of any HCR Contracts in which they are involved. The form includes spaces for a description of the requirement, signature, and date. This is a standard compliance document rather than a solicitation for products or services.