D.6 Appendix A Conflict of Interest.pdf
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November 4, 2015 VHA HANDBOOK 1660.03
A-1
APPENDIX A
SAMPLE CONFLICT OF INTEREST ACKNOWLEDGMENT
Instructions:
This acknowledgement form is to be completed by each Chief of Staff, physician, clinician, researcher and allied health supervisor or manager, and any individual who assumes these duties in the future or any VA employee who participates in HCR Contracts.
Description of Requirement:
I have received, read and agree to abide by the guidance contained in Veterans Health Administration (VHA) Handbook 1660.03 as it pertains to conflicts of interest in contracts or agreements for sharing of HCR.
I have taken the appropriate Tier Level Medical Sharing/Affiliate Office Customer training commensurate with my position. VHA MSO Customer Resource Center
I understand that this acknowledgement may be placed in my Electronic Official Personnel File and that a copy will be placed in the official procurement file of any HCR Contracts in which I am involved.
(Signature) (Date)
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