Thank you for taking the time to complete the USPSTF Conflict of Interest Disclosure Form. In your role as a member of the USPSTF, the Task Force Chairs and AHRQ require full disclosure of all possible conflicts of interest. Please note that disclosure of potential conflicts of interest is part of the process to eliminate bias and ensure transparency of the process. Disclosing potential conflicts of interest does not necessarily disqualify you as a participant. For the purposes of this disclosure form, individuals should disclose all interests that apply to all USPSTF topics in development. For those topics for which you have disclosed interests on a previously submitted Disclosure Form, please update any new interests since the last disclosure was provided. For any new topics, please provide a full disclosure.
Full Name
Insert Task Force member name
U.S. Preventive Services Task Force Disclosure Form
Disclosure of Financial Interests: Task Force Members
For the purposes of this Disclosure Form, individuals should disclose all interests that apply to all USPSTF topics that will be covered during the upcoming meeting as well as all topics in development. For "Type of Financial Interest," please select one of A to H according to the following definitions:
A) Ownership or owning stock (stock, options, warrants) or holding debt or other significant proprietary interests or investments in any third party that could be affected by a USPSTF decision on a specific topic.
B) Having an employment, independent contractor, or consulting relationship or other contractual arrangements, whether written or unwritten, with an entity that could be financially affected by a Task Force decision.
C) Receiving a proprietary research grant or receiving patents, royalties, or licensing fees from such an organization.
D) Participating on a company's proprietary governing boards.
E) Participating in speakers bureaus.
F) Receiving honoraria.
G) Receiving payment as an expert witness for a plaintiff or a defendant.
H) Receiving remuneration for services with respect to transactions involving parties with a financial interest in the outcome of a USPSTF decision. This may include clinical specialty practice.
| Type of Financial Interest | Amount ($) | Description | Date Potential COI Occurred (mm/yy) |
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|---|---|---|---|---|
| Task Force Member Name | ||||
| Task Force Member Name | ||||
Disclosure of Financial Interests: Immediate Family Members and Close Personal Relationships
For the purposes of this Disclosure Form, individuals should disclose all interests that apply to all USPSTF topics that will be covered during the upcoming meeting as well as all topics in development. For "Type of Financial Interest," please select one of A to H according to the following definitions:
A) Ownership or owning stock (stock, options, warrants) or holding debt or other significant proprietary interests or investments in any third party that could be affected by a USPSTF decision on a specific topic.
B) Having an employment, independent contractor, or consulting relationship or other contractual arrangements, whether written or unwritten, with an entity that could be financially affected by a Task Force decision.
C) Receiving a proprietary research grant or receiving patents, royalties, or licensing fees from such an organization.
D) Participating on a company's proprietary governing boards.
E) Participating in speakers bureaus.
F) Receiving honoraria.
G) Receiving payment as an expert witness for a plaintiff or a defendant.
H) Receiving remuneration for services with respect to transactions involving parties with a financial interest in the outcome of a USPSTF decision. This may include clinical specialty practice.
| Friend or Family Member | Relationship | Type of Financial Interest | Amount ($) | Description | Date Potential COI Occurred (mm/yy) | |
|---|---|---|---|---|---|---|
| Task Force Member Name | ||||||
| Task Force Member Name | ||||||
Disclosure of Nonfinancial Interests
For the purposes of this Disclosure Form, individuals should disclose all interests that apply to all USPSTF topics that will be covered during the upcoming meeting as well as all topics in development. For "Role," please select one of A to E according to the following definitions:
A) Public comments and testimony.
B) Leadership role on a panel.
C) Substantial career efforts/interests in a single topic area.
D) Previously published opinions.
E) Advocacy or policy positions.
| Organization | Role | Type of Participation (Paid/Unpaid) | Description | Date Potential COI Occurred (mm/yy) | |
|---|---|---|---|---|---|
| Task Force Member Name | |||||
| Task Force Member Name | |||||
To the best of your ability, please respond yes or no to each of the questions listed below. If the answer is yes for any question, please include details or references that may be helpful in evaluating the potential influence of each relationship or personal belief. A "yes" answer will not necessarily disqualify you from participating in Task Force activities.
| Response (Required) | If Yes, Explain | |
|---|---|---|
| A. Do you have strongly held beliefs related to the topic area that would make it difficult for you to work in an unbiased manner on any new or ongoing Task Force topics? | ||
| B. Have you ever authored, coauthored, or publicly provided an opinion related to any new or ongoing Task Force topics? | ||
| C. Could your institution benefit or be harmed based on whether the Task Force finds benefit, harm, or no difference in outcomes? | ||
| D. Would the support you would receive from your institution (or primary mentor) change if your work on the Task Force generated a strong negative reaction from peers outside your institution? | ||
| E. To the best of your knowledge, do you work for, or are you a member of, an organization with a stated position (e.g., position statement, blog, editorial, legislature or legal testimony, or related document) related to any new or ongoing Task Force topics? | ||
| F. Are you involved in formulating/voting for positions in any organization with a stated position related to any new or ongoing Task Force topics? | ||
| G. Could this recommendation statement conflict with policies you have promoted or are obliged to follow? |
In the space below, please describe any nonfinancial interests for your immediate family members and close personal relationships related to all new and continuing topics.
As a member of the USPSTF, I affirm the following:
I have listed all personal financial interests from the past 36 months in the Disclosure Form (including equity positions, consulting agreements, or employment arrangements with an entity that could be financially affected by a Task Force decision) for myself, my immediate family members, and close personal relationships for all new topics covered during this meeting, all topics in development, as well as any changes in my situation since this form was last completed for continuing topics. Period of disclosure is 36 months prior to the meeting and continues until the final reports are completed. I have declared any other real or perceived nonfinancial conflict(s) of interest for myself, immediate family members, and close personal relationships in the Disclosure Form related to the subject matter of all new topics covered during this meeting, all topics in development, as well as any changes in my situation since this form was last completed for continuing topics.
I understand and agree to the above two items.
If for any reason you feel you cannot sign this statement as worded or if you have further questions, please contact the Chairs.
Current as of: July 2017
Internet Citation: Appendix II. USPSTF Conflict of Interest Disclosure Form. U.S. Preventive Services Task Force. July 2017.