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 serves as a conflict of interest acknowledgment to be completed by Chiefs of Staff, physicians, clinicians, researchers, allied health supervisors or managers, and any individual who assumes duties in the future or any VA employee who participates in Health Care Resources (HCR) Contracts. The acknowledgment requires signatories to confirm they have received, read, and agreed 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 confirm 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 a blank line for describing the specific requirement and requires a signature and date from the individual acknowledging these conflict of interest obligations.