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CABARRUS COUNTY HOME HEALTH <br />Conflict of Interest Disclosure Questionnaire <br /> <br />Pursuant to the purposes and intent of Cabarms County Home Health's conflict of interest policy, <br />I hereby state that I and/or members of my immediate family have the following affiliations or <br />interests and have taken part in the following transactions which, when considered in conjunction <br />with my position as a member of Cabarrus County Home Health Advisory Board, the Cabarrus <br />County Board of Commissioners or management staff, might possibly effect a conflict of interest. <br /> <br />In my opinion, none of the interests disclosed below place me in a position of having a conflict <br />with the Agency. (If such an interest might present a conflict, please check this box [ ] and note <br />details on reverse side. <br /> <br />Interests: Identify any interests, other than investments, of yourself or your <br />immediate family which may present a conflict. <br /> <br />Outside Activities: Identify any outside activities of yourself or your immediate family <br />which may present a conflict. <br /> <br />Acceptance of Gifts or Hospitality: I hereby certify that neither I nor any member of my <br />immediate family have accepted gifts, gratuities, or entertainment that might tend to <br />influence my judgment or actions concerning business of the Agency, except as listed <br />below: <br /> <br />Other: List any other activities in which you or your immediate family are engaged <br />which could possibly be regarded as constituting a conflict of interest. <br /> <br />I hereby agree to report to the Director any further situation which may develop before <br />completion of my next questionnaire. <br /> <br />Signature Date <br /> <br />Please complete and return to the Director within two (2) weeks of receipt. <br /> <br /> <br />