**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]{.underline}

**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]{.underline} 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]{.underline}. (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]{.underline}. 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]{.underline}. 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]{.underline}. (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]{.underline}

\(ii\) 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:]{.underline}

*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:]{.underline}***

*Public reporting burden for this collection of information is estimated
to average 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 collection of
information. Send comments regarding this burden estimate or any other
suggestions for reducing this burden to Tom Gleason, NOAA Fisheries
Office of Management & Budget, 1315 East-West Highway, Silver Spring,
Maryland 20910.*

*Notwithstanding any other provisions of the law, no person is required
to respond to, nor shall any person be subjected to a penalty for
failure to comply with, a collection of information subject to the
requirements of the Paperwork Reduction Act, unless that collection of
information displays a currently valid OMB Control Number.*