Conflict of Interest Disclosure for Studies Related to G

OMB Control No.: 0648-0567

Expires: XX/XX/20XX

National Oceanic and Atmospheric Administration

CONFLICT OF INTEREST DISCLOSURE

For Studies Related to Government Regulation

NAME: TELEPHONE:

ADDRESS:

EMAIL ADDRESS:

CURRENT EMPLOYER:

PEER REVIEW SUBJECT: _____________________________________________________

INSTRUCTIONS

Please complete this form, sign and date it on the last page, attach a copy of your curriculum vitae, and return the form to the NOAA Office coordinating the peer review process. Retain a copy for your records.

It is essential that peer reviewers of influential scientific information or highly influential scientific assessments that NOAA intends to disseminate not be compromised by any significant conflict of interest. For this purpose, the term "conflict of interest" means any financial or other interest which conflicts with the service of the individual because it (1) could significantly impair the individual's objectivity or (2) could create an unfair competitive advantage for any person or organization. Except for those situations in which NOAA determines that a conflict of interest is unavoidable and promptly and publicly discloses the conflict of interest, no individual can be appointed to review information subject to the OMB Peer Review Bulletin if the individual has a conflict of interest that is relevant to the functions to be performed.

The term "conflict of interest" means something more than individual bias. There must be an interest, ordinarily financial, that could be directly affected by the work of the peer reviewers.

Conflict of interest requirements are objective and preventive. They are not an assessment of one's actual behavior or character, one's ability to act objectively despite the conflicting interest, or one's relative insensitivity to particular dollar amounts of specific assets because of one's personal wealth. Conflict of interest requirements are objective standards designed to eliminate certain specific, potentially compromising situations from arising, and thereby protect the individual, other peer reviewers, NOAA, and the public interest. The individual, the other peer

reviewers, and NOAA should not be placed in a situation where the findings and conclusions of a review could be reasonably questioned, and perhaps discounted or dismissed, simply because of the existence of conflicting interests.

The term "conflict of interest" applies only to current interests. It does not apply to past interests that have expired, no longer exist, and cannot reasonably affect current behavior. Nor does it apply to possible interests that may arise in the future but do not currently exist, because such future interests are inherently speculative and uncertain. For example, a pending formal or informal application for a particular job is a current interest, but the mere possibility that one might apply for such a job in the future is not a current interest.

The term "conflict of interest" applies 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. Thus, in assessing an individual's potential conflicts of interest, consideration must be given not only to the interests of the individual but also to the interests 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. Consideration must also be given to the interests of those for whom one is 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).

This disclosure form is used for screening potential peer reviewers of “influential scientific information” or “highly influential scientific assessments” subject to the OMB Peer Review Bulletin and relied on by NOAA to support a regulatory action. For such peer reviews, the focus of the conflict of interest inquiry is on the identification and assessment of any interests that may be directly affected by the use of the peer reviewer’s findings and conclusions in the regulatory process. The concern is that if an individual (or others with whom the individual has substantial common financial interests) has specific interests that could be directly affected by the regulatory action, the individual’s objectivity could be impaired.

Such interests could include an individual’s stock holdings in excess of $10,000 in a company potentially affected by the regulation at issue or being an officer, director, or employee of such a company. Serving as a consultant to such a company could constitute an interest if the consulting relationship with the business could be directly affected or is directly related to the subject matter of the regulatory process.

An individual’s other possible interests might include, for example, relevant patents and other forms of intellectual property, serving as an expert witness in litigation directly related to the subject matter of the 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 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. Consideration would also need to be given to the interests of others with whom the individual has substantial common financial interests – particularly spouses, employers, clients, and business or research partners.

The following questions are designed to elicit information from you concerning possible conflicts of interest that are relevant to the functions to be performed in the course of the peer review in which you have been asked to serve.

1. EMPLOYMENT. (a) If the peer review report(s) resulting from this peer review activity were relied on for government regulatory action or inaction with respect to the matters addressed in the peer review report(s) -

(i) If you are employed or self-employed, could your current employment or self-employment (or your spouse’s current employment or self-employment) be directly affected?

(ii) To the best of your knowledge, could any financial interests of your (or your spouse’s) employer, or, if self-employed, your (or your spouse’s) clients and/or business partners be directly affected?

(iii) If you are an officer, director or trustee of any corporation or other legal entity, could the financial interests of that corporation or legal entity be directly affected?

(iv) If you are a consultant (whether full-time or part-time), could there be a direct effect on any of your current consulting relationships?

(v) Regardless of the potential effect on the consulting relationship, do 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), to the best of your knowledge are there any federal conflict of interest restrictions that may be applicable to your service in connection with this committee activity?

If the answer to all of the above questions under EMPLOYMENT is either “no” or “not applicable,” check here (NO).

If the answer to any of the above questions under EMPLOYMENT is “yes,” check here (YES), and briefly describe the circumstances on the last page of this form.

2. INVESTMENT INTERESTS. Taking into account stocks, bonds, and other financial instruments and investments including partnerships (but excluding broadly diversified mutual funds and any investment or financial interest valued at less than $10,000), if the peer review report(s) resulting from this peer review activity were relied on for government regulatory action or inaction with respect to the matters addressed in the peer review report(s) -

(a) Do 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) any stocks, bonds or other financial instruments or investments that could be affected, either directly or by a direct effect on the business enterprise or activities underlying the investments?

(b) Do 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?

If the answer to all of the above questions under INVESTMENT INTERESTS is either “no” or “not applicable,” check here (NO).

If the answer to any of the above questions under INVESTMENT INTERESTS is “yes,” check here (YES), and briefly describe the circumstances on the last page of this form.

3. PROPERTY INTERESTS. Taking into account real estate and other tangible property interests, as well as intellectual property (patents, copyrights, etc.) interests, if the peer review report(s) resulting from this peer review activity were relied on for government regulatory action or inaction with respect to the matters addressed in the peer review report(s) -

(a) Do 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, do 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?

If the answer to all of the above questions under PROPERTY INTERESTS is either “no” or “not applicable,” check here (NO).

If the answer to any of the above questions under PROPERTY INTERESTS is “yes,” check here (YES), and briefly describe the circumstances on the last page of this form.

4. RESEARCH FUNDING AND OTHER INTERESTS. (a) 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 peer review report(s) resulting from this peer review activity were relied on for government regulatory action or inaction with respect to the matters addressed in the peer review report(s) -

(i) Could the research funding and support for you or your close research colleagues and collaborators be directly affected, or

(ii) 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 of the regulatory process, do 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)?

(b) Is the central purpose of the peer review for which this disclosure form is being prepared a critical review and evaluation of your own work or that of your employer?

(c) Do 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 peer review activity?

(d) To the best of your knowledge, will your participation in this peer review activity enable you to obtain access to a competitor’s or potential competitor’s confidential proprietary information?

(e) Could your service as a peer reviewer of influential scientific information or a highly influential scientific assessment that NOAA intends to disseminate create a specific financial or commercial competitive advantage for you or others with whom you have substantial common financial interests?

(f) If the peer review activity for which this form is being prepared involves reviews of specific applications and proposals for contract, grant, fellowship, etc. awards to be made by NOAA or other sponsors, do 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 peer review?

(g) If the peer review activity for which this form is being prepared involves developing requests for proposals, work statements, and/or specifications, etc., are you interested in seeking an award under the program for which the peer review on which you have been asked to serve is developing the request for proposals, work statement, and/or specifications – or, are you employed in any capacity by, or do 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?

If the answer to all of the above questions under RESEARCH FUNDING OR OTHER INTERESTS is either “no” or “not applicable,” check here (NO).

If the answer to any of the above questions under RESEARCH FUNDING OR OTHER INTERESTS is “yes,” check here (YES), and briefly describe the circumstances below.

5. ADDITIONAL INFORMATION. If there are relevant aspects of your background or present circumstances (e.g., positions of any organizations or groups with which you are closely identified or associated) not addressed above that might reasonably be construed by others as affecting your judgment in matters within the assigned task of the peer review you have been invited to undertake, and therefore might constitute an actual or potential source of bias, please describe them briefly.

EXPLANATION OF “YES” RESPONSES:

During your period of service in connection with the activity for which this form is being completed, any changes in the information reported, or any new information, which needs to be reported, should be reported promptly by written or electronic communication to NOAA.

YOUR SIGNATURE DATE

Reviewed by:

Name Date

Paperwork Reduction Act Statement:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0648-0567. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to Adrienne Thomas, 1315 East West Hwy, Bldg. SSMC3, Silver Spring, MD 20910-3282, (240) 457-9227, Adrienne.thomas@noaa.gov.

Privacy Act Statement

Authority: The collection of this information is authorized under 5 U.S.C. 301, Departmental Regulations and 15 U.S.C. 1512, Powers and duties of Department.

Purpose: To address questions of conflict of interest, individuals selected to perform peer review of scientific information subject to the Final Information Quality Bulletin for Peer Review issued by OMB are required to submit certain background information and information regarding conflicts of interest to NOAA for review. 

NOAA Routine Uses: NOAA will use this information in addressing and resolving questions of conflict of interest when selecting peer reviewers who are not federal government employees. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among NOAA staff for work-related purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of Records Notice Commerce/DEPT-11, Candidates for Membership, Members, and Former Members of Department of Commerce Advisory Committees.

Obligation to Respond: Furnishing this information is voluntary. However, failure to submit the requested information will disqualify an individual from performing peer review of scientific information.

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