Conflict of Interest Long 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: Long 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:
Phone:

Fax:____________________________________

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 one 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.

This form is intended to obtain information on potential or real conflicts of interest related to the subject activity.
For questions 1 through 6:
Please provide the information requested below regarding relevant organizational affiliation, government service,
public statements and positions, expert testimony, research support, and additional information (if any).
Information is “relevant” if it is related to, or might reasonably be of interest to others with respect to, your
knowledge, experience, and personal perspectives regarding the subject matter and issues to be addressed by
this activity. If some or all of the requested information is contained within your curriculum vitae, you may simply
attach your CV and refer to the specific page and line on your CV where the information appears. You may
supplement this with additional information as appropriate.
1. Compensated and non-compensated employment - for panel member (or individual) and spouse sources of compensated and uncompensated employment, including government service, for the
preceding 24 months including a brief description of work.
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2. Research funding - for panel member (or individual)- sources of research support and project funding,
including from any federal or state government agency, for the preceding 24 months for which the panel
member served as the Principal Investigator, significant collaborator or Project Manager or Director. For
panel member’s spouse, a general description of research and project activities in the preceding 24
months.

3. Consulting - for panel member (or individual) - compensated consulting activities during the preceding
24 months including names of clients if compensation provided 15% or more of annual compensation.
For panel member’s spouse, a general description of consulting activities for the preceding 24 months.

4. Expert witness activities - for panel member (or individual), sources of compensated expert witness
activities and a brief description of issue and testimony. For panel member’s spouse, a general
description of expert testimony provided in the preceding 24 months.

5. Assets: Stocks, Bonds, Real Estate, Business, Patents, Trademarks, and Royalties. For panel
member (or individual), spouse and dependent children - specific financial holdings that collectively had
a fair market value greater than $15,000 at any time during the preceding 24 month period (excluding
well-diversified mutual funds, money market funds, treasury bonds and personal residence.)

6. Liabilities - For panel member (or individual), spouse and dependent children, liabilities over $10,000
owed at any time in the preceding twelve months (excluding a mortgage on personal residence, home
equity loans, automobile and consumer loans.)

For questions 7 through 15:
Please answer the following questions by checking “yes or “no.”. 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:

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7. 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 __

8. 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?
Yes __ No __

9. 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 __

10. 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 __

11. 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 __

12. 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 __

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

14. 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 __

15. 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 __
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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: _____________________________________

Reviewed by:________________________________
Project Manager

________________________
Date

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