D 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 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 Health Care Resources (HCR) Contracts. The acknowledgment requires the signatory to confirm receipt, reading, and agreement 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 certify that they have completed appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with their position and may access the VHA MSO Customer Resource Center for additional information. The form also requires acknowledgment that the signed document will be placed in the signatory's Electronic Official Personnel File and a copy will be filed in the official procurement file of any HCR Contracts in which the individual is involved. The form includes signature and date lines for completion.