Medical Staff Conflict of Interest Disclosure Form
Name
Department
Position
Email
Are you or any related individual involved in any financial or other relationships that could present a conflict of interest related to your duties?
Yes
No
If yes, please describe in detail
Have you disclosed this conflict of interest to your supervisor or relevant authority?
Yes
No
Additional Comments
I certify that the above information is complete and accurate to the best of my knowledge. I understand that failure to disclose a conflict of interest may result in disciplinary action.
Signature
Date