Student Conflict of Interest Disclosure Form

This form is for medical students who may be impacted by the University and College of Medicine policies on conflicts of interest regarding family members, health care providers and close personal associates (friendships and professional relationships (for details, refer to page 103 of The Compass). Information submitted will be reviewed by course leadership, and students will be notified of the decision in time to plan their schedule accordingly.

Student Information
I am disclosing a family member, health care provider or close personal associate on staff at a hospital teaching site or outpatient site that may impact clinical assignments and/or the assignment of a grade.
For which year of the curriculum is this disclosure?

Please provide the following information about each person with whom you have a potential conflict of interest:

Conflict of Interest # 1
Conflict of Interest # 2
Conflict of Interest # 3
Conflict of Interest # 4
Conflict of Interest # 5
Comments
Do you have additional conflicts of interest to disclose?
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