Conflict of Interest Disclosure Form

Conflict of Interest Disclosure Form

Note: A potential or actual conflict of interest exists when commitments and obligations are likely to becompromised by the nominator(s)’other material interests, or relationships (especially economic),particularly if those interests or commitments are not disclosed.

This Conflict of Interest Form should indicate whether the nominator(s) has an economic interest in, oracts as an officer or a director of, any outside entity whose financial interests would reasonably appearto be affected by the addition of the nominated condition to the newborn screening panel. Thenominator(s) should also disclose any personal, business, or volunteer affiliations that may give rise to areal or apparent conflict of interest. Relevant Federally and organizationally established regulations andguidelines in financial conflicts must be abided by. Individuals with a conflict of interest should refrainfrom nominating a condition for screening.




Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), orcircumstances that you believe could contribute to a conflict of interest:

_____ I have no conflict of interest to report.

_____ I have the following conflict of interest to report (please specify other nonprofit and for-profitboards you (and your spouse) sit on, any for-profit businesses for which you or an immediate familymember are an officer or director, or a majority shareholder, and the name of your employer and anybusinesses you or a family member own:




I hereby certify that the information set forth above is true and complete to the best of my knowledge.


Date: _________________________________________