Form APHIS Form 6004 APHIS Form 6004 Peer Reviewer Information

U nited States Animal and Plant Health 1400 Independence Ave. SW

Department of Inspection Service Washington, DC 20250

Agriculture

[Full name of prospective peer reviewer]

[Title], [Organization]

[Street address]

[City, State, Zip Code]

Dear [Last Name of Peer Reviewer], [Date]

In order to ensure the highest level of quality and credibility for the scientific information we use in making policy and disseminating information to the public, we are requesting assistance from several independent, nationally-recognized scientific experts to serve as peer reviewers. Over the next several weeks, they will evaluate the following scientific document,

____________________[Name of scientific document] ______________.

You have been selected to serve as an expert in the field of [Name of scientific field and specialization.] We would greatly appreciate your participation in this effort. If you agree to assist us, we will ask you to provide an objective evaluation of the technical merits of specific aspects of this document such as its design, methodology, data sources, data analyses, and inferences. You will be expected to hold in abeyance any concerns you may have that are not part of your scientific charge. Any input on the policy determinations will be solicited from a wider audience according to standard administrative procedures.

If you would like to participate in this peer review, we first need to ask you to carefully consider whether any of your personal affiliations and involvements would pose a conflict of interest or create the appearance of such a conflict to members of the public. We are asking about this because we want to alleviate future concerns and avoid potential embarrassment to you, the reviewer, or APHIS. The peer reviewers’ report and identities will be posted on the agency website for the public to see, although your specific comments may not be attributed to you. Also, this conflict of interest consideration is consistent with Office of Management and Budget’s procedures, which say,

Agencies shall make a special effort to examine prospective reviewers’ potential financial conflicts, including significant investments, consulting arrangements, employer affiliations and grants/contracts. Financial ties of potential reviewers to regulated entities (e.g., businesses), other stakeholders, and regulatory agencies shall be scrutinized when the information being reviewed is likely to be relevant to regulatory policy. The inquiry into potential conflicts goes beyond financial investments and business relationships and includes work as an expert witness, consulting arrangements, honoraria and sources of grants and contracts. [Office of Management and Budget, “Final Information Quality Bulletin for Peer Review,” 70 Federal Register 2670, January 14, 2005]

We will not ask you to provide extensive information about your personal affairs in writing, but we do request that you review your situation according to instructions on the attached form and withdraw from consideration if you find that you have conflicts of interest. If you feel confident that you have no actual or implied conflicting interests with respect to this document, please certify yourself by submitting the attached form to the Peer Review Administrator for this document, who is

[Name of Peer Review Administrator for the document]

APHIS, Program Name Unit xxx,

4700 River Road

Riverdale, MD 20737-1234

(301) 734-xxxx

([email protected])

We are providing a copy of OMB’s Peer Review Bulletin for reference. If you have any questions about what constitutes a conflict, contact the Peer Review Administrator who can also provide you with more details about the analytical charge, the timing and deadlines, and possible compensation.

Thank you very much for your consideration. We look forward to hearing from you and working with you on this peer review.

Sincerely,

[Title of Program Official]

[Name of APHIS Major Program]

[Address of Program Official]

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OMB Approved 0579-0304

EXP. XX/XXXX

USDA ANIMAL AND PLANT HEALTH INSPECTION SERVICE (APHIS)

PEER REVIEWER'S CERTIFICATION REGARDING CONFLICT OF INTEREST

Privacy Act Notice: This information requested on this form is being collected in order to meet the requirements of Public law No.106-554, §515(a) and the Office of Management and Budget's "Final Information Quality Bulletin for Peer Review", 70 Federal Register 2664-2677. It will be used to determine the suitability of external scientists for service in peer reviewing important scientific documents that will be used in policy making and disseminated to the public. Failure to submit this information may result in non selection of a prospective reviewer.

PART A • INSTRUCTIONS

APHIS understands the importance of and accepts responsibility for ensuring that all nonfederal peer reviewers who are recruited by the Agency have no significant potential conflict of interest with respect to peer review of a specific scientific document that will be used for purposes of making policy or dissemination to the public. These instructions refer to the form in Part B - Peer Reviewer Information.

1. Please list the title of the specific scientific publication you will review.

2. Review your current employment and your significant investments, property, and research funding or grants, and record any that pose potential conflicts of interest (COI) related to the scientific document and/or the subject matter you have been asked to address with your specific scientific expertise. To assist you, APHIS is providing the following definition:

• Conflict of interest (COI) 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.

• The term conflict of interest~ means something more than individual bias. There must be an Interest, ordinarily financial, that could be directly affected by work as an Agency peer reviewer.

• Conflict of interest requirements are not an assessment of one's actual behavior or character, one's ability to act objectively despite the conflicting Interest, or one's sensitivity to potential wealth. The standards are designed to prevent certain specific, potentially compromising situations from arising, and thereby to protect the individual, the Agency, and the public interest. They are 10 prevent situations where others might question, discount, or dismiss, the value of work performed.

• COI applies only to current interests, not to past interests that have expired, no longer exist, and cannot reasonably affect current behavior. Nor does it apply to interests that may arise in the future.

• The term “conflict of interest” applies not only 10 the personal financial interests of the individual, but also to interests of others with whom one has substantial common financial interests if these 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 interest of the individual's spouse and minor children, 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).

3. If you have questions about whether you might have a COI, you may consult the guidance provided on the World Wide Web at http://www.nationalacademies.org/coi/bi-coi_form-0.pdf by the National Academies of Science and/or contact the APHIS Peer Review Administrator of the scientific document you have been asked to review. Please return the signed and dated form 10 APHIS' Peer Review Administrator or the person serving as his or her agent before beginning work. If you decide not to participate, or prefer not to for any reason, please accept our thanks for your consideration.

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APHIS FORM 6004 (OCT 2009)

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0304. The time required to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.				OMB Approved 0579-0304 EXP. XX/XXXX
USDA-APHIS PART B - PEER REVIEWER INFORMATION
NAME		TELEPHONE NUMBER
ADDRESS		EMAIL ADDRESS
		CURRENT EMPLOYER
DOCUMENT TO BE REVIEWED:
___________ ___________ ___________ ____________	1. Employment: A person may have a conflict of interest if he/she holds employment by an organization that is likely to be directly affected by this review. In addition to working at a job for wages or a salary, "employment" here includes: self-employment, engaging in consulting relationships, providing expert testimony, and holding positions as an officer, director, or trustee for any legal entity that might be affected by this review. It does not include compensation from USDA APHIS for participating in this peer review. 2. Investments: A person may have a conflict of interest if he/she holds investments that may be affected by this review. "Investments" here include stocks, bonds, stock options, other financial investments, and partnerships that might be affected by this review, but excludes broadly diversified mutual funds. 3. Property: A person may have a conflict of interest if he/she owns property that may be directly affected by this review. "Property" here includes real estate, intellectual property such as patents or copyrights, and other tangible property interests that might be affected by this review. 4. Grants and Research Funding: A person may have a conflict of interest if he/she has received a grant, honorarium, award, or research funding from an entity likely to be affected by the review. "Grants and Research Funding" here includes any funding or support for equipment, facilities, industrial partnerships, and research assistants or other personnel that might be affected by this review.
By initialing above and signing below I certify that I recognize the conflict of interest concerns that are relevant to this peer review. I have reviewed my affairs in the categories listed and, to the best of my knowledge; I have no financial ties to regulated entities, stakeholder organizations, or the agency that would significantly interfere with my ability and willingness to render objective, scientific judgment in conducting a peer review of the document requested by USDA-APHIS. I agree that, if my situation should change during the period of time that I am working on the requested peer review, or if I should learn that members of the public legitimately perceive that I am not able and willing to so perform, I will inform the USDA-APHIS Peer Review Administrator and discuss whether I should discontinue my involvement with the peer review.
SIGNATURE			DATE

APHIS FORM 6004

OCT 2009