OMB Control Number: 1218-0255
Expiration Date: 02/28/2017
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:
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 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. |
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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:
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 __
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?
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 __
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 __
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 __
Have you had previous involvement with the development of the document (or review materials) you have been asked to review?
Yes __ No __
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 __
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: _____________________________________
Reviewed by:________________________________ ________________________
Project Manager Date
OSHA10-80.1
| File Type | application/msword |
| File Title | Occupational Safety and Health Administration (OSHA) |
| Author | KSchalk |
| Last Modified By | Owen, Todd - OSHA |
| File Modified | 2017-02-15 |
| File Created | 2017-02-15 |