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Burrell College of Osteopathic Medicine Burrell College of Osteopathic Medicine
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Conflict of Interest – Faculty

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  • Conflict of Interest – Faculty
Conflict of Interest – FacultySam Turner2021-01-11T15:41:33-07:00
  • This conflict of interest form contains information that may have direct bearing on your employment and completing this form is a condition of your employment. This form will be stored by The Office of Human Resources and considered confidential. The information submitted on this form is only available to individuals duly charged with the responsibility for review and may be released only in accordance with and as required by federal or state law; or regulations; or lawful court order.
  • Please include the following in the space provided below: name of entity/activity; location; services/products offered; your relationship to the entity; anticipated dates of activity; estimated hours per week (if during work hours indicate whether annual leave will be take); and indicate any fees or gifts received, expenses paid or donations of goods or services with an aggregated value of $100 or greater in the previous 12-month period.
  • If yes, please include in the section below, the following: name of entity or nature of activity, compensation received including gifts, donations or services.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, please explain below.
  • If yes, in the section provided below, please include the following: describe the activity and provide details regarding the use of the institution resources (e.g. % of use, times per year, etc.) including the details of arrangements for reimbursement of usage.
  • If yes, please explain below
  • If yes, please explain below
  • Date Format: MM slash DD slash YYYY
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CONTACT OUR OFFICE

Burrell College of Osteopathic Medicine
3501 Arrowhead Dr
Las Cruces, NM 88001
Phone: 575.674–BCOM (2266)
Fax: 575.674.2267

 

Burrell General Info: info@bcomNM.org
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