Appendix II

U.S. Preventive Services Task Force Disclosure Form

This Disclosure Form relates to current topics as listed on page 3 of this form. Those topics for which you have disclosed interests on a previously submitted a Disclosure Form, please update any new interests since the last disclosure was provided. For any new topics, please provide a full disclosure. Period of disclosure is 12 months prior to the date of form completion and continues until final reports are completed.

Disclosure of Significant Financial Interests

Please list each corporation, company, firm, research organization, educational institution, or other organization or institution (proprietary and not-for-profit, domestic and foreign) in which you, your spouse, and dependent children have significant financial interests that are related to the subject matter discussed at this meeting (see p. 3 for topic list). List anything of monetary value that when aggregated for you, your spouse, and dependent children exceeds $10,000 in value as determined through reference to public prices or other reasonable measure of fair market value, or represents more than 5% ownership interest in any single entity. Please specify source and type of payment. Such interests include but are not limited to: (a) salary or other payments for services (e.g., consulting fees or honoraria); (b) equity interests (e.g., stocks, stock options or other ownership interests); or (c) intellectual property rights (e.g., patents, copyrights and royalties from such rights).

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Disclosure of Business and Professional Interests

Please list below your business and professional affiliations with entities that are related to or have interest in the subject matter discussed at this meeting (see p. 3 for topic list). List the name of any corporation, professional society, association, or panel, company, firm, government agency (federal, state and local), research organization, educational institution, or other organization or institution (proprietary and not-for-profit, domestic and foreign) in which your services have been, or will be or is expected to be provided, with or without compensation, including on a part-time or seasonal basis, as an (a) officer; (b) medical staff; (c) board member; (d) owner; (e) trustee; (f) director; (g) expert advisor; or (h) consultant.

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Disclosure of Intellectual Interests

AHRQ recognizes that potential intellectual interests are likely to be numerous because Task Force members are chosen for their national reputations on prevention issues; and their work may be sufficiently well-known that users of Task Force products might doubt the objectivity of the process if such members are known to have taken leadership roles in discussion and vote on recommendations regarding that topic. These may range from trivial to substantial. The Task Force previously identified the following as possible intellectual conflicts: (a) public comments and testimony; (b) expert testimony for malpractice; (c) leadership role on a panel; (d) substantial career efforts/interests in a single topic area.

Please list instances in which you have disclosed publicly, either by official verbal or written statements, your position for or against counseling, screening, or intervention that may affect objectivity pertaining to the topics discussed at this meeting.

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As a member of the USPSTF, I affirm the following:

• I have listed all personal financial interests from the past 12 months in the Disclosure Form (including equity positions, consulting agreements, or employment arrangements) that are related to the topics, including related products that will be discussed at this meeting. (Please see p. 3 for topic list.) Period of disclosure is 12 months prior to the meeting and continues until the final reports are completed.
• I have listed all my business and professional affiliations in the Disclosure Form from the past 12 months that have entities related to or have interest in the subject matter of the topics discussed at this meeting. (Please see p. 3 for topic list.) Period of disclosure is 12 months prior to the meeting and continues until the final reports are completed.
• I have declared any other real or apparent intellectual conflict(s) of interest related to the subject matter of the current and future topics. (Please see p. 3 for topic list.)

Print Name_____________________________

Signature______________________________

Date__________________________________

If for any reason you feel you cannot sign this statement as worded or if you have further questions, please contact Tess Miller at (301) 427-1585.

PLEASE FAX COMPLETED FORM TO (301) 427-1597 ATTN Gloria Washington

Attachment: List of all current and future (next quarter) topics

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