Conflict of Interest and Disclosure Form

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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
For OSHA Task/Activity: ___________________________________________________________________



Tier 1: The review material is considered an “influential” scientific document, therefore requiring
potential reviewers to fill out the Tier 1 form.



Tier 2: The review material is considered a “highly influential scientific document,” therefore
requiring potential reviewers to fill both the Tier 1 and Tier 2 forms.

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 the Tier 1 Form for Influential Scientific Activity/Document, and one hour for respondent to
complete both the Tier 1 and Tier 2 Forms for Highly Influential Scientific Activity/Document. 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.
TIER 1 FORM – INFLUENTIAL SCIENTIFIC ACTIVITY/DOCUMENT
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 __
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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?
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.
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___________________________________________

_______________________
Date

Your signature

Name: _____________________________________

Reviewed by:________________________________
Project Manager

________________________
Date

TIER 2 FORM – HIGHLY INFLUENTIAL SCIENTIFIC DOCUMENT/ACTIVITY
This form is intended to obtain information on potential or real conflicts of interest related to the subject activity.
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.
10.

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.

11.

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.

12.

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.

13.

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.

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14.

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.)

15.

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.)

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.

___________________________________________

_______________________
Date

Your signature

Name: _____________________________________

Reviewed by:________________________________
Project Manager

________________________
Date

APPENDIX A
Additional Information on Determining Conflict of Interest
for Those Who Are Not To Be Appointed as Federal Employees
This appendix provides further guidance to individuals for the purposes of completing these forms. Persons
subject to Tier 1 reporting need only complete the Tier 1 portion of the form. Persons required to complete the
Tier 2 portion must complete both portions. You must respond to each of the questions in accordance with its
own terms. However, for the purpose of responding to question 8 on Tier 1 portion of the form, you should
consider the following factors in deciding whether you must report that you have "any actual or potential personal
conflict of interest or bias." The term "bias" is intended to be read broadly and includes any factors that that you
believe might be perceived as improperly influencing your actions on this project. The term "conflict of interest"
is defined more specifically below. Should you have any questions, you should seek advice from the Task
Manager.
For the purposes of completing this form, the term "conflict of interest" does not refer to past interests that have
expired, no longer exist and cannot reasonably affect current behavior. Nor does it refer to possible interests
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that may arise in the future but do not currently exist and are speculative or uncertain. For example, a pending
formal or informal application for a particular job should be considered, but it is not necessary to consider the
mere possibility that one might apply for such a job in the future.
The term "conflict of interest" refers 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. These interests include those 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. You should also consider the interests of those for whom you are 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).
In connection with your work on a covered project, you must identify any interests that may be directly affected
by the use of such reports by OSHA. For example, if OSHA were conducting a study of proposed modifications
in the government regulation of a particular industry, you must identify any interests that would be directly
affected by the results of the expert panel’s findings, including the interests of others with whom you have
substantial common financial interests.
Such interests will include your stock holdings or being an officer, director, or employee of an entity or company.
Serving as a consultant to the company could constitute such an interest if the consulting relationship with the
company could be directly affected by, or is directly related to, the subject matter or a potential regulatory
process.
Other possible interests that you must consider include, for example, relevant patents and other forms of
intellectual property, serving as an expert witness in litigation directly related to the subject matter or the potential
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 by, 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). You must also consider such interests of others with whom you have substantial common financial
interests -- particularly spouses, employers, clients, and business or research partners.

EMPLOYMENT. (a) If the reports resulting from this activity were to provide the basis for government regulatory
action or inaction with respect to the matters addressed in the reports, you must consider whether -(i) your current employment or self-employment (or your spouse's current employment or selfemployment) could be directly affected.
(ii) any of your (or your spouse's) financial interests and employer's interests or, if self-employed, your
(or your spouse's) clients and/or business partners could be directly affected.
(iii) the financial interests of a corporation or other legal entity for which you are an officer, director or
trustee could be directly affected.
(iv) there could be a direct effect on any of your current consulting relationships.
(v) regardless of the potential effect on the consulting relationship, 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), consider whether, to the best
of your knowledge, there are any federal conflict of interest restrictions that may be applicable to your service in
connection with this activity.
(c) Consider whether your employer (e.g., a private foundation) is a co-sponsor of this project.

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INVESTMENT INTERESTS. Taking into account stocks, bonds, and other financial instruments and
investments including partnerships, if the reports resulting from this activity were to provide the basis for
government regulatory action or inaction with respect to the matters addressed in the reports, consider whether-(a) any stocks, bonds or other financial instruments or investments that 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) could
be affected, either directly or by a direct effect on the business enterprise or activities underlying the
investments.
(b) 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.
PROPERTY INTERESTS. Taking into account real estate and other tangible property interests, as well as
intellectual property (patents, copyrights, etc.) interests, if the reports resulting from this activity were to provide
the basis for government regulatory action or inaction with respect to the matters addressed in the reports,
consider whether -(a) 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, 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.
RESEARCH FUNDING AND OTHER INTERESTS. 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 reports resulting from this activity were to provide the basis for government regulatory
action or inaction with respect to the matters addressed in the reports, consider whether -(a) the research funding and support for you or your close research colleagues and collaborators could be
directly affected.
(b) 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 or the potential regulatory process, 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).
(c) the central purpose of the project for which this disclosure form is being prepared is a critical review and
evaluation of your own work or that of your employer.
(d) 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 activity.
(e) to the best of your knowledge, your participation in this activity will enable you to obtain access to a
competitor's or potential competitor's confidential proprietary information.
(f) your service on the activity on which you have been invited to serve could create a specific financial or
commercial competitive advantage for you or others with whom you have substantial common financial interests.
(g) if the activity for which this form is being prepared involves reviews of specific applications and proposals for
contract, grant, fellowship, or other awards to be made by sponsors, 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
committee.

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(h) if the activity for which this form is being prepared involves developing requests for proposals, work
statements, and/or specifications, etc., you are interested in seeking an award under the program for which the
activity/task on which you have been invited to serve is developing the request for proposals, work statement,
and/or specifications -- or, you are employed in any capacity by, or 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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