Attachment 1 - Conflict of Interest.pdf

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

The form is a template to be completed by each Chief of Staff, physician, clinician, researcher, allied health supervisor or manager, and any individual who assumes these duties in the future or participates in Healthcare Contracting and Relationship (HCR) Contracts. The acknowledgment requires the signatory 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 Healthcare Contracting and Relationship services. The form includes a blank field for description of the requirement and requires the individual to acknowledge they have completed the appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position, with a reference to the VHA MSO Customer Resource Center. The acknowledgment further states that the form may be placed in the employee's Electronic Official Personnel File and that a copy will be placed in the official procurement file of any HCR Contract in which the individual is involved. The form requires signature and date upon completion.