Conflict of Interest Form

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Overview

This form is intended for use if you think you may have an actual or potential Conflict of Interest. Please see the Guidelines for Review and Approval of Conflict of Interest to determine whether you have an actual or potential conflict of interest.

This form is intended for you to report an actual or potential conflict of interest about yourself. It is not intended for reporting actual or potential conflicts of interests concerning other Abbott employees.

Items marked with a diamond ♦ are required fields.

My Information

UPI

♦

First Name

M.I.

♦

Last Name

♦

Email Address

(Format: username@domain.com)

Phone Number

Include the area code, extension,
and/or dialing codes if applicable.

Alternative Phone

Include the area code, extension,
and/or dialing codes if applicable.

Division

(Select One)

♦

Country

(Select One)

Conflict of Interest Details

♦

Have you reported this actual or potential conflict of interest to your manager?

Yes No

(Select One)

Attention: Manager’s written approval (and possibly your Manager’s Manager) is required to approve all actual or potential conflicts. You will be prompted to attach the Actual or Potential Conflict of Interest Approval (page 14 of the COI Guidelines) after submitting this Conflict of Interest form.

♦

Select the type of actual or potential type of conflict you wish to report.

Attention: You may only report one type of actual or potential conflict of interest at a time. If you have additional existing or potential conflicts, please submit a separate report for each conflict.

♦

Provide the details of your actual or potential conflict of interest:

Identify any conditions or limitations will minimize or eliminate the actual or potential conflict of interest:

Acknowledgement & Submit

♦

Acknowledgement

I have read and understood the Abbott’s Code of Conduct and Conflict of Interest Policy.

The information contained in this form is true and accurate to the best of my knowledge and belief.