D 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 designed for completion by Chiefs of Staff, physicians, clinicians, researchers, allied health supervisors or managers, and any individual who assumes these duties in the future or participates in Health Care Related (HCR) Contracts at VA facilities. 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 acknowledge that they have completed appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position, with reference to the VHA MSO Customer Resource Center. The form further requires acknowledgment that the completed acknowledgment may be placed in the signatory's Electronic Official Personnel File and that a copy will be filed in the official procurement file of any HCR Contracts in which they are involved. The form includes signature and date fields for execution.