Conflict of Interest and Confidentiality Certification

This form serves as a representation of the absence of conflict of interest for the competition below.

Based on the list of application(s) to be reviewed for HRSA-18-001, 004, 005 , Ryan White HIV/AIDS Program Part C HIV Early Intervention Services Program: Existing Geographic Service Areasfor whose Objective Review Committee I am a confirmed member, I certify that: (Please check one box)

I do nothave an affiliation with ANY application or organization applying for funding under this competition.

I dohave an actual or potential conflict of interest with respect to the following application(s). Please list application(s) numbers and explanations below:

Application # / Application Name / Reason for Conflict
1.
2.
3.

**Please complete the form by September 25, 2017 and scan and emailorfax to (877) 595-7309**

An individual has a conflict of interest in an application if that person, or a close relative (parent, spouse, sibling, child or domestic partner) or professional associate(colleague, scientific mentor or current student with whom you have conducted professional activities within the current year)of that person, actually has or has the appearance of having:

  1. Received or could receive a direct financial benefit of any amount deriving from an application or proposal under review;
  2. Has any known relationship with an individual employed by the applicant organization or an individual mentionedin the proposal; or
  3. Any other interest in the application or proposal that is likely to bias the individual's evaluation of that application or proposal.

I understand that I may not review, score, rate, be present for or otherwise participate in the discussion of or be privy to the review comments for any application in which I have a potential or actual conflict of interest.

CONFIDENTIALITY:

I fully understand the confidential nature of the application (s), evaluations, and any review group discussions related thereto and agree: (1) to destroy all copies of review-related materials; (2) to erase all electronic review-related materials; (3) not to discuss these materials or the review proceedings with any individual except the staff of the Division of Independent Review (DIR) and Health Resources and Services Administration (HRSA) program and grants management officials; and (4) to refer all inquiries made of me concerning any aspect of the review proceedings to the HRSA DIR Review Administrator in charge of the review.

I certify that I will maintain strict confidentiality and to the best of my knowledge, I certify that the above information is accurate and true. (Original signatures only)

Reviewer Signature: ______Date:______

Printed Name:______Email: ______