Instructions for Use

Use this form to disclose actual, potential, and perceived conflicts of interest as required by POL-009 (Conflicts of Interest), Section 5.2. The form is maintained by the Compliance Officer and collected by the Employee Relations Specialist. This form satisfies the duty to disclose when completed in full and signed.

When to complete this form:

1. At hire. During onboarding, before or as part of your first week.
2. Annually. During the annual compliance refresh, even if you have nothing to disclose. A signed "no conflicts" response is required each year (Part 1).
3. Within 10 business days of a change. Whenever a change in your circumstances creates a new conflict, submit an updated form to the Compliance Officer.

How to use this form:

1. Complete the header in full, including the trigger that prompted this disclosure.
2. If you have nothing to disclose this cycle, complete Part 1 (the annual "no conflicts" attestation), then sign and date. You do not need to complete Parts 2 through 5.
3. If you have anything to disclose, leave Part 1 unchecked and complete each of Parts 2 through 5 that applies. When in doubt, disclose and let the Compliance Officer make the determination (POL-009, Section 5.2).
4. Outside employment that does not involve a prohibited element is permitted but must still be disclosed in Part 2.
5. Submit the completed form per the routing note at the end of the form. The Compliance Officer reviews each disclosure, determines whether a conflict exists, and records the outcome in the Conflict of Interest Disclosure Log (CFM-004).
6. Where the Compliance Officer determines that a conflict exists, you and your supervisor will complete a Conflict of Interest Management Plan (CFM-003).

Form Realization and Fallback

This is the canonical, authoritative version of Form CFM-002, maintained in the compliance documentation. It defines the fields, attestations, and structure that any realization of the form must capture.

ABAS may collect this form through an electronic realization: a web form, a tablet form, or direct electronic submission to company files. Any electronic realization must capture the same content and carry the form identifier CFM-002, so the policy and SOP refer to the form by its identifier rather than to any one channel.

The documented form here is always available as a fallback. It can be printed and completed on paper whenever an electronic form is unavailable or a paper form is otherwise needed, for example during a system outage or a loss of internet access.

Alternate-language and electronically read (screen-reader) versions are derived from this canonical form and must match it, so the same content stays authoritative across every realization.

Disclosure Form

Employee Information

Part 1: Annual "No Conflicts" Attestation

Complete this part only if you have nothing to disclose this cycle.

☐ I attest that I have no actual, potential, or perceived conflict of interest to disclose at this time. I understand my duty to disclose any conflict that later arises within 10 business days, and to comply with any approved management plan.

If you checked the box above, skip Parts 2 through 5 and sign below. Otherwise, leave it unchecked and complete each part that applies.

Part 2: Outside Employment and Private ABA Work (POL-009, Section 5.3)

Do you hold any outside employment, including private ABA or related clinical work? ☐ No ☐ Yes

If yes, describe the employer, the nature of the work, and your role:

Required attestation. ABAS prohibits the activities listed below. Check each box to confirm your outside work does not involve it. If you cannot confirm any item, do not check it and describe the situation in the space provided so the Compliance Officer can review it.

• ☐ I am not providing private ABA or related services to current ABAS clients or their immediate family members.
• ☐ I am not soliciting or diverting ABAS clients, referrals, or prospective clients to a private practice or another provider.
• ☐ I am not using ABAS time, facilities, materials, client records, or systems for outside work.
• ☐ My outside work does not prevent me from meeting my scheduled ABAS duties.

If you could not confirm any item above, explain here:

Part 3: Financial Interests in Vendors and Referral Sources (POL-009, Section 5.4)

Do you or an immediate family member hold a financial interest in a vendor, referral source, or competing provider? ☐ No ☐ Yes

If yes, identify the entity, the nature of the interest, and whose interest it is (yours or a named family member's):

Do your ABAS duties involve selecting, negotiating with, approving, or managing the relationship with that entity? ☐ No ☐ Yes ☐ Not applicable

Part 4: Family and Personal Relationships (POL-009, Section 5.5)

Do you have an immediate family member, or a person with whom you have a close personal relationship, who is in your supervisory chain, where you or they hire, supervise, evaluate, discipline, set compensation for, or assign clients to the other? ☐ No ☐ Yes

If yes, identify the person, the relationship, and the supervisory or decision-making overlap:

Part 5: Gifts (POL-009, Section 5.6)

Have you been offered a gift from a client, family, vendor, or referral source that exceeded nominal value (worth $50 or more from a single source in a calendar year), or any cash or cash equivalent in any amount? ☐ No ☐ Yes

If yes, identify the source, describe the gift and its approximate value, and state whether it was declined or returned:

Routing

Submit the completed form to the Compliance Officer.

• If this disclosure names or involves the Compliance Officer, submit it instead to the Executive Director.
• If this disclosure names or involves the Executive Director, submit it to the Compliance Committee.

Employee Signature

Form CFM-002 · Owning policy: POL-009 (Conflicts of Interest). Version number and effective date are set in ABAS's document-control record at adoption.

Retention

Completed disclosure forms are part of the compliance program files. Per POL-009, Section 5.0:

• The Employee Relations Specialist forwards each completed form to the Compliance Officer.
• The Compliance Officer records the disclosure and the conflict determination in the Conflict of Interest Disclosure Log (CFM-004) and retains the form in the compliance program files.
• Where a conflict exists, the form is retained together with its management plan (CFM-003).

The Compliance Officer is custodian of completed forms and maintains them at a company-owned level, consistent with the compliance program's records practices.