APPENDIX A Conflict of Interest disclosure
2024 Annual Conflict of Interest Self-Disclosure Assessment ( v08Dec2023 )
Section 1 – Business Relationship
Have you or a family member had a business relationship , financial interest , provides any services or items , or employment relationship with any entity that does business with or competes with Renown Health or a Renown Health affiliated entity ?
* ◯ No * ◯ Yes
Please provide the name of who may have a business relationship , financial interest , provides any services or items , or employment relationship with any entity that does business with or competes with Renown Health or a Renown Health affiliated entity .
As applicable , please select : self-identify , family member , or both .
* Select to self-identify * Select to identify an immediate family member
Please provide the name of the family member .
Please provide your relationship to the family member named above .
What is the name of the business or entity ?
Please provide the nature of the Financial and / or Business Relationship ( s ). Once you have completed this question , please continue to the next section .
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