HERC Member Conflict of Interest/Personal Interest Form

This Conflict of Interest/Personal Interest form is designed to convey transparency regarding the perspectives of members of the Commission and its subcommittees. Most members are employed in a field related to topics that may come before the Commission or have personal beliefs which will influence their decisions, so it's important to engage in this process.

Filling out this form does not affect your obligation under ORS 244 (Oregon's conflict of interest law). Even after you fill out this form, if a vote could affect your finances or those of a relative, you are required to declare a potential conflict of interest prior to a vote. If a vote would affect your finances or those of a relative, you are required to abstain from discussion and from voting on that matter.

In addition to the above requirements, HERC asks that members of the Commission and its subcommittees disclose a broader range of personal interests, including past financial relationships, areas of research, professional interests and public advocacy. However, this form is a public record, so please do not disclose any personal health information, trade secrets, or other protected information. You are not required to disclose interests related to health conditions of yourself or relatives.

This form will inform HERC staff and the chair of past and ongoing interests which may affect your perspective, and is a step in complying with the requirements of the HERC bylaws. You are required to fill out the form annually, and encouraged to update it when you change employment or have other significant changes in the above stated areas (e.g., research, advocacy).
 
Please see the HERC bylaws and your HERC handbook for more information about your duties and obligations as a member of HERC or a subcommittee. Thank you for your important work.

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* 1. Type of Appointment

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* 2. Name

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* 3. Employer(s)/Business(es)

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* 4. Official Clinical/Academic/Professional Title (if any):

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* 5. Clinical/Academic Specialty (if relevant)

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* 6. Certifications or Fellowships (if any):

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* 7. Brief biographical statement (Please include your profession, employer, clinical specialty and focus of any research activities). Click here to see your current bio on the HERC website. Your entry will be used to update (or create) your biographical information on our website and to meet requirements about personal interest disclosure. We may edit it for clarity and consistency, but will let you review any changes we make.

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* 8. I have filled this out previously and my information has not changed since last year’s attestation.

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