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 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 Health Care Contracts. Signatories acknowledge receipt and understanding of VHA Handbook 1660.03 guidance regarding conflicts of interest in contracts or agreements for sharing of health care resources (HCR). The form requires individuals to confirm they have completed appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position and direct them to the VHA MSO Customer Resource Center for training information. Signatories further acknowledge that the acknowledgment may be placed in their Electronic Official Personnel File and a copy will be filed in the official procurement file of any HCR Contracts in which they are involved. The form requires signature and date fields and includes a blank line for description of the requirement relevant to the individual's position.