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 to be completed by Chiefs of Staff, physicians, clinicians, researchers, allied health supervisors or managers, and any individuals who assume these duties in the future or participate in VHA 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 involving the sharing of HCR. Signatories must also attest that they have completed appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position and understand that the acknowledgment may be placed in their Electronic Official Personnel File, with a copy filed in the official procurement file of any HCR Contracts in which they are involved. The form includes signature and date lines and a blank space for describing the requirement or position involved.