OSHA 10-08.1 Conflict of Interest Short Form

OMB Control Number: 1218-0255
Expiration Date: XX/XX/2023

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 half 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?
Yes __ No __

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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: _____________________________________

Reviewed by:________________________________
Project Manager

________________________
Date

OSHA10-80.1

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