Conflict of Interest Short Form

PRELIMINARY DRAFT
OMB Control Number: 1218-0255
Expiration Date: xx/xx/2013

Background Information and Conflict of Interest Disclosure
for Peer Reviewers Who Are Not To Be Appointed as Federal Employees: Short Form
For OSHA Task/Activity: ___________________________________________________________________

Please see Appendix A for detailed definitions of what constitutes a “conflict of interest,” in the
categories of 1) employment; 2)investing interests; 3) property interests; and 4) research and other
interests.
Name:
Title:
Organization:
Fax:____________________________________

Phone:
E-mail:

Shipping Address (No P.O. Boxes please): ____ Home

____ Work

Street:
City:

State:

Postal/Zip Code: _____

____

Public reporting for this voluntary collection of information is estimated to average 0.5 hour for respondents
completing this form. This time includes the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information.
Persons are not required to respond to the collection of information unless it displays a currently valid Office
of Management and Budget Control Number. If you have any comments regarding this estimate or any other
aspect of this information collection, including suggestions for reducing this burden, please send them to
OSHA's Directorate of Standards and Guidance, Room N-3609, 200 Constitution Avenue, NW, Washington,
DC 20210.

Instructions
If the activity you have been asked to participate in focuses on a specific chemical, agent, or topic of concern,
please answer the following questions. If you answer “yes” to any of the questions, please provide a full
explanation, specifically emphasizing those areas that could raise questions or concerns about your impartiality
or the creation of an unfair competitive advantage:
1. To the best of your knowledge and belief, is there any connection between the subject chemical, agent,
or topic and any of your and/or your spouse’s compensated or uncompensated employment, including
government service, that occurred in the past 24 months?
Yes __ No __

2. To the best of your knowledge and belief, is there any connection between the subject chemical, agent,
or topic and any of your and/or your spouse’s research support and project funding, including from any
federal or state government agency, during the past 24 months?

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Yes __ No __

3. To the best of your knowledge and belief, is there any connection between the subject chemical, agent,
or topic and any consulting agreement that you and/or your spouse may have entered into in the past 24
months?
Yes __ No __

4. To the best of your knowledge and belief, is there any connection between the subject chemical, agent,
or topic and any expert witness activities engaged in by you and/or your spouse in the past 24 months?
Yes __ No __

5. To the best of your knowledge and belief, have you, your spouse, or dependent child held in the past 24
months, any financial holdings (excluding well-diversified mutual funds and holdings with a value less
than $15,000) with any connection to the subject chemical, agent, or topic?
Yes __ No __

6. Have you made any public statements or taken public positions on, or closely related to, the subject
chemical, agent, or topic under review?
Yes __ No __

7. Have you had previous involvement with the development of the document (or review materials) you
have been asked to review?
Yes __ No __

8. To the best of your knowledge and belief, is there any other information that might reasonably raise a
question about actual or potential personal conflict of interest or bias (See Appendix A for factors to be
considered in considering whether you have an actual or potential bias or conflict of interest.)?
Yes __ No __

9. To the best of your knowledge and belief, is there any financial benefit that might be gained by you or
your spouse as a result of the outcome of this review.
Yes __ No __

During your period of service in connection with the activity for which this form is being completed, any
changes in the information you provided, or any new relevant information, should be reported promptly
by written or electronic communication to the responsible entity contracting with you for your services.

___________________________________________
Your signature

_______________________
Date

Name: _____________________________________

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Reviewed by:________________________________
Project Manager

________________________
Date

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