Conflict of Interest Disclosure for Studies Related to G

OMB Control No.: 0648-xxxx
Expires: xx/xx/2xxx

National Oceanic and Atmospheric Administration

CONFLICT OF INTEREST DISCLOSURE
For Studies Related to Government Regulation

NAME:

TELEPHONE:

ADDRESS:

EMAIL ADDRESS:
CURRENT EMPLOYER:
PEER REVIEW SUBJECT:

_____________________________________________________
INSTRUCTIONS

Please complete this form, sign and date it on the last page, attach a copy of your
curriculum vitae, and return the form to the NOAA Office coordinating the peer review
process. Retain a copy for your records.
It is essential that peer reviewers of influential scientific information or highly influential
scientific assessments that NOAA intends to disseminate not be compromised by any significant
conflict of interest. For this purpose, the term "conflict of interest" means any financial or
other interest which conflicts with the service of the individual because it (1) could
significantly impair the individual's objectivity or (2) could create an unfair competitive
advantage for any person or organization. Except for those situations in which NOAA
determines that a conflict of interest is unavoidable and promptly and publicly discloses the
conflict of interest, no individual can be appointed to review information subject to the OMB
Peer Review Bulletin if the individual has a conflict of interest that is relevant to the functions to
be performed.
The term "conflict of interest" means something more than individual bias. There must be an
interest, ordinarily financial, that could be directly affected by the work of the peer reviewers.
Conflict of interest requirements are objective and preventive. They are not an assessment of
one's actual behavior or character, one's ability to act objectively despite the conflicting interest,
or one's relative insensitivity to particular dollar amounts of specific assets because of one's
personal wealth. Conflict of interest requirements are objective standards designed to eliminate
certain specific, potentially compromising situations from arising, and thereby protect the
individual, other peer reviewers, NOAA, and the public interest. The individual, the other peer
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reviewers, and NOAA should not be placed in a situation where the findings and conclusions of
a review could be reasonably questioned, and perhaps discounted or dismissed, simply because
of the existence of conflicting interests.
The term "conflict of interest" applies only to current interests. It does not apply to past interests
that have expired, no longer exist, and cannot reasonably affect current behavior. Nor does it
apply to possible interests that may arise in the future but do not currently exist, because such
future interests are inherently speculative and uncertain. For example, a pending formal or
informal application for a particular job is a current interest, but the mere possibility that one
might apply for such a job in the future is not a current interest.
The term "conflict of interest" applies not only to the personal interests of the individual but also
to the interests of others with whom the individual has substantial common financial interests if
these interests are relevant to the functions to be performed. Thus, in assessing an individual's
potential conflicts of interest, consideration must be given not only to the interests of the
individual but also to the interests of the individual's spouse and minor children, the individual's
employer, the individual's business partners, and others with whom the individual has substantial
common financial interests. Consideration must also be given to the interests of those for whom
one is acting in a fiduciary or similar capacity (e.g., being an officer or director of a corporation,
whether profit or nonprofit, or serving as a trustee).
This disclosure form is used for screening potential peer reviewers of “influential scientific
information” or “highly influential scientific assessments” subject to the OMB Peer Review
Bulletin and relied on by NOAA to support a regulatory action. For such peer reviews, the focus
of the conflict of interest inquiry is on the identification and assessment of any interests that may
be directly affected by the use of the peer reviewer’s findings and conclusions in the regulatory
process. The concern is that if an individual (or others with whom the individual has substantial
common financial interests) has specific interests that could be directly affected by the regulatory
action, the individual’s objectivity could be impaired.
Such interests could include an individual’s stock holdings in excess of $10,000 in a company
potentially affected by the regulation at issue or being an officer, director, or employee of such a
company. Serving as a consultant to such a company could constitute an interest if the
consulting relationship with the business could be directly affected or is directly related to the
subject matter of the regulatory process.
An individual’s other possible interests might include, for example, relevant patents and other
forms of intellectual property, serving as an expert witness in litigation directly related to the
subject matter of the regulatory process, or receiving research funding from a party that would be
directly affected by the regulatory process if the research funding could be directly affected or is
directly related to the subject matter of the regulatory process and the right to independently
conduct and publish the results of this research is limited by the sponsor. Consideration would
also need to be given to the interests of others with whom the individual has substantial common
financial interests – particularly spouses, employers, clients, and business or research partners.

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The following questions are designed to elicit information from you concerning possible
conflicts of interest that are relevant to the functions to be performed in the course of the peer
review in which you have been asked to serve.
1. EMPLOYMENT. (a) If the peer review report(s) resulting from this peer review activity
were relied on for government regulatory action or inaction with respect to the matters addressed
in the peer review report(s) (i) If you are employed or self-employed, could your current employment or selfemployment (or your spouse’s current employment or self-employment) be directly
affected?
(ii) To the best of your knowledge, could any financial interests of your (or your
spouse’s) employer, or, if self-employed, your (or your spouse’s) clients and/or business
partners be directly affected?
(iii) If you are an officer, director or trustee of any corporation or other legal entity,
could the financial interests of that corporation or legal entity be directly affected?
(iv) If you are a consultant (whether full-time or part-time), could there be a direct effect
on any of your current consulting relationships?
(v) Regardless of the potential effect on the consulting relationship, do you have any
current or continuing consulting relationships (including, for example, commercial and
professional consulting and service arrangements, scientific and technical advisory board
memberships, serving as an expert witness in litigation, or providing services in exchange
for honorariums and travel expense reimbursements) that are directly related to the
subject matter of the possible government regulatory action or inaction?
(b) If you have ever been a U.S. Government employee (either civilian or military), to the best
of your knowledge are there any federal conflict of interest restrictions that may be applicable to
your service in connection with this committee activity?
If the answer to all of the above questions under EMPLOYMENT is either “no” or
(NO).
“not applicable,” check here

here

If the answer to any of the above questions under EMPLOYMENT is “yes,” check
(YES), and briefly describe the circumstances on the last page of this form.

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2. INVESTMENT INTERESTS. Taking into account stocks, bonds, and other financial
instruments and investments including partnerships (but excluding broadly diversified mutual
funds and any investment or financial interest valued at less than $10,000), if the peer review
report(s) resulting from this peer review activity were relied on for government regulatory action
or inaction with respect to the matters addressed in the peer review report(s) (a) Do you or your spouse or minor children own directly or indirectly (e.g., through a trust or an
individual account in a pension or profit-sharing plan) any stocks, bonds or other financial
instruments or investments that could be affected, either directly or by a direct effect on the
business enterprise or activities underlying the investments?
(b) Do you have any other significant financial investments or interests such as commercial
business interests (e.g., sole proprietorships), investment interests (e.g., stock options), or
personal investment relationships (e.g., involving parents or grandchildren) that could be
affected, either directly or by a direct effect on the business enterprise or activities underlying the
investments?
If the answer to all of the above questions under INVESTMENT INTERESTS is
either “no” or “not applicable,” check here
(NO).
If the answer to any of the above questions under INVESTMENT INTERESTS is
“yes,” check here
(YES), and briefly describe the circumstances on the last page
of this form.
3. PROPERTY INTERESTS. Taking into account real estate and other tangible property
interests, as well as intellectual property (patents, copyrights, etc.) interests, if the peer review
report(s) resulting from this peer review activity were relied on for government regulatory action
or inaction with respect to the matters addressed in the peer review report(s) (a) Do you or your spouse or minor children own directly or indirectly any such property
interests that could be directly affected?
(b) To the best of your knowledge, do any others with whom you have substantial common
financial interests (e.g., employer, business partners, etc.) own directly or indirectly any such
property interests that could be directly affected?
If the answer to all of the above questions under PROPERTY INTERESTS is either
“no” or “not applicable,” check here
(NO).
If the answer to any of the above questions under PROPERTY INTERESTS is
(YES), and briefly describe the circumstances on the last page
“yes,” check here
of this form.

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4. RESEARCH FUNDING AND OTHER INTERESTS. (a) Taking into account your research
funding and other research support (e.g., equipment, facilities, industry partnerships, research
assistants and other research personnel, etc.), if the peer review report(s) resulting from this peer
review activity were relied on for government regulatory action or inaction with respect to the
matters addressed in the peer review report(s) (i) Could the research funding and support for you or your close research colleagues and
collaborators be directly affected, or
(ii) If you have any research agreements for current or continuing research funding or
support from any party whose financial interests could be directly affected, and such funding or
support is directly related to the subject matter of the regulatory process, do such agreements
significantly limit your ability to independently conduct and publish the results of your research
(other than for reasonable delays in publication in order to file patent applications)?
(b) Is the central purpose of the peer review for which this disclosure form is being prepared a
critical review and evaluation of your own work or that of your employer?
(c) Do you have any existing professional obligations (e.g., as an officer of a scientific or
engineering society) that effectively require you to publicly defend a previously established
position on an issue that is relevant to the functions to be performed in this peer review activity?
(d) To the best of your knowledge, will your participation in this peer review activity enable you
to obtain access to a competitor’s or potential competitor’s confidential proprietary information?
(e) Could your service as a peer reviewer of influential scientific information or a highly
influential scientific assessment that NOAA intends to disseminate create a specific financial or
commercial competitive advantage for you or others with whom you have substantial common
financial interests?
(f) If the peer review activity for which this form is being prepared involves reviews of specific
applications and proposals for contract, grant, fellowship, etc. awards to be made by NOAA or
other sponsors, do you or others with whom you have substantial common financial interests, or
a familial or substantial professional relationship, have an interest in receiving or being
considered for awards that are currently the subject of the review being conducted by this peer
review?
(g) If the peer review activity for which this form is being prepared involves developing requests
for proposals, work statements, and/or specifications, etc., are you interested in seeking an award
under the program for which the peer review on which you have been asked to serve is
developing the request for proposals, work statement, and/or specifications – or, are you
employed in any capacity by, or do you have a financial interest in or other economic
relationship with, any person or organization that to the best of your knowledge is interested in
seeking an award under this program?

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If the answer to all of the above questions under RESEARCH FUNDING OR
OTHER INTERESTS is either “no” or “not applicable,” check here (NO).
If the answer to any of the above questions under RESEARCH FUNDING OR
OTHER INTERESTS is “yes,” check here
(YES), and briefly describe the
circumstances below.
5. ADDITIONAL INFORMATION. If there are relevant aspects of your background or present
circumstances (e.g., positions of any organizations or groups with which you are closely
identified or associated) not addressed above that might reasonably be construed by others as
affecting your judgment in matters within the assigned task of the peer review you have been
invited to undertake, and therefore might constitute an actual or potential source of bias, please
describe them briefly.

EXPLANATION OF “YES” RESPONSES:

During your period of service in connection with the activity for which this form is being
completed, any changes in the information reported, or any new information, which needs to be
reported, should be reported promptly by written or electronic communication to NOAA.

YOUR SIGNATURE

DATE

Reviewed by:
Name

Date

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