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Hhs-520 FORM HHS-520

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
REQUEST FOR APPROVAL OF OUTSIDE ACTIVITY
Standards of Ethical Conduct Regulation
HHS Supplemental Ethics Regulation
(5 CFR 2635.803, 5 CFR 5501.106(d))
Initial Request Revised Request Renewal
DATE FILED
I. EMPLOYEE INFORMATION
1. EMPLOYEE'S NAME (Last, First, MI)
2. AGENCY (Operating/Staff Divison) (Subcomponent)
3. TITLE OF POSITION
4. GRADE/STEP
5. FEDERAL SALARY
6. APPOINTMENT TYPE
PAS/PA
Non-Career SES Career SES
Schedule C
Commissioned Corps
GS
Title 42
Other
7. FINANCIAL DISCLOSURE FILING STATUS
Public (OGE 278)
Confidential (OGE 450)
None
8. OFFICE ADDRESS
STREET
CITY
STATE
ZIP
9. OFFICE CONTACT INFORMATION
TELEPHONE FAX
CELL EMAIL
10. NAME OF IMMEDIATE SUPERVISOR 11. TITLE OF SUPERVISOR
12. SUPERVISOR CONTACT INFORMATION
TELEPHONE FAX
CELL EMAIL
AGENCY USE ONLY
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 1 OF 16
PSC Publishing Services (301) 443-6740
EF
II. OUTSIDE ACTIVITY INFORMATION
1. Nature of Outside Activity
Indicate the type of activity for which you request prior approval, and describe fully the specific duties or services to be performed.
Professional or Consultative Activities
Teaching, Speaking, Writing or Editing Board Service Expert Witness
Other
Describe:
If you will provide personal services or products directly to multiple clients, patients, customers, or others, as a self-employed individual or as an
independent contractor, alone or jointly with others, check the box below and specify the type of activity or business in which you propose to be
engaged, such as legal, medical, accounting, or sales (specify industry or economic sector) and identify any partners or others with whom you provide
services or products jointly. Estimate the total number of clients, patients, customers, or persons to whom you would provide services or products
during the activity period, rather than listing them in Part II, Item 2.
Self-Employed Activity
For activities involving teaching, speaking, or writing, provide a syllabus, outline, summary, synopsis, draft, or similar description of the content and
subject matter involved in the course, speech, or written product (including, if available, a copy of the text of any speech) and the proposed text of any
disclaimer that indicates that the views expressed do not necessarily represent the views of the agency or the United States. Check the applicable
boxes indicating that these materials are attached. If you are unable to provide this information, or will be delayed in submitting the attachments,
please explain below.
Subject Matter of Activity
Text of Disclaimer
Explain:
2. Outside Employer or Other Entity
Identify the outside employer or other person for whom or organization for which the proposed activity will be performed or conducted. Give the name
and title of a contact person. In Items 3 and 4, provide address and contact information for the outside entity.
OUTSIDE ENTITY NAME
CONTACT PERSON TITLE
3. Outside Entity Address
STREET
CITY
STATE
ZIP
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PAGE 2 OF 16
II. OUTSIDE ACTIVITY INFORMATION (continued)
TELEPHONE
4. Contact information
FAX
CELL EMAIL
5. Location
Indicate the location where the activity or services will be performed.
6. Travel
Indicate whether travel is involved, and if so, whether the transportation, lodging, meals, or per diem will be at your own expense or provided by the
outside entity in kind or through reimbursement. Describe arrangements and provide estimated costs of items to be furnished or reimbursed by the
outside entity.
Yes
At own Expense
In-Kind or Reimbursed
Estimated Amount
$
No
Describe:
7. Time
Provide details with respect to the duration, frequency, and timing of the activity. If your request for prior approval is granted, the approval is effective for
a period not to exceed one year from the date of approval. If you wish to continue an activity beyond the one year approval period, you must renew your
request no later than thirty days prior to the expiration of the period authorized.
a. Period Covered
From (mm/dd/yy):
To (mm/dd/yy):
b. Estimated Total Time Devoted to the Proposed Activity
Hours per Day Days per Week
Weeks per Year
c. Will work be performed entirely outside of usual working hours?
Yes No
(If "no," estimate the number of hours or days that you will be absent from work and indicate the type of leave to be requested.)
8. Compensation
Indicate whether the activity is compensated, and if so, answer the questions below.
Yes
No
a. Method or Basis of Compensation (Check all boxes that apply)
Fee
Honorarium
Retainer
Salary
Advance Royalty Stock
Stock Options
Non-Travel Related Expenses (describe)
Other (specify)
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 3 OF 16
II. OUTSIDE ACTIVITY INFORMATION (continued)
b. Compensation Amount
Indicate the total amount of compensation to be received for the proposed activity for the period covered by this request. Do not include the amount of
any travel expenses to be provided by the outside entity that were reported in Part II, Item 6.
$
c. Payor
If any compensation will be received from a payor other than the entity to which personal services will be provided, identify the payor and explain.
d. Funding Source
Indicate whether any compensation is derived from an HHS grant, contract, cooperative agreement, or other source of HHS funding or if the services
to be performed are related to an activity funded by HHS, regardless of the specific source of the compensation.
Yes (If "yes," describe)
No
e. Grantee, Contractor, or Other Status
For activities involving the provision of consultative or professional services, indicate whether the client, employer, or other person on whose behalf
the services are performed is receiving, or intends to seek, an HHS grant, contract, cooperative agreement, or other funding relationship.
Yes (If "yes," describe)
No
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 4 OF 16
II. OUTSIDE ACTIVITY INFORMATION (continued)
f. Record of Prior Compensation from Same Source
Identify the source, activity, amount and date of any compensation received, or due for services performed, within the last six calendar years and the
current year through the date this request is submitted, from the person for whom or the organization with which the current work or activity will be
done (including any amount received or due from an agent, affiliate, parent, subsidiary, or predecessor of the proposed payor). This information must
be provided as to any outside activity performed for the person or organization that is the subject of this request for approval. Include any prior
activity that is the same or similar to the present request, as well as any unrelated activity involving the same source.
YEAR SOURCE ACTIVITY AMOUNT $ DATE
CURRENT
1
2
3
4
5
6
ADDITIONAL SPACE
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 5 OF 16
III. OFFICIAL DUTY INFORMATION
1. Nature of Official Duties
Describe the principal duties and responsibilities of your current position. You may attach a copy of your position description in lieu of providing the
description unless you currently have significant duties or assignments that are not reflected in that document.
Position Description Attached
2. Relationship of Official Duties to Outside Activity
Describe any official duties that relate in any way to the proposed activity. If none, explain why.
3. Effect of Official Duties on Outside Employer
In performing your official duties, explain how your actions or the matters upon which you may be called upon to work could affect the interests of the
person for whom or the organization for which the proposed activity will be performed. If the exercise of your official duties would not have such an
effect, explain why.
4. Assignments Involving Outside Employer
Describe any official duty assignments or other interactions you have had that involve the person for whom or the organization for which the proposed
activity will be performed and indicate when such assignments or interactions occurred. If none, explain.
5. CERTIFICATION
The undersigned employee certifies that the notices in Part VIII have been read and understood and that the statements made and information provided on
this form are true, complete, and correct to the best of the individual's knowledge.
EMPLOYEE SIGNATURE
DATE
HHS-520 (1/06) (Previous Editions Obsolete)
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IV. SUPERVISOR REVIEW
1. Summary of Applicable Law
An employee cannot undertake an outside activity that conflicts with the employee's official duties. An activity conflicts with official duties: (a) if it is
prohibited by statute or regulation; or (b) if, under the standards in 5 CFR 2635.402 and 2635.502, it would require the employee's recusal from matters so
central or critical to the performance of his or her official duties that the employee's ability to perform the duties of his or her position would be materially
impaired. Such a recusal would likely arise where the outside activity involves a person or entity that is regulated by, does business with, receives grants or
other benefits from, or is otherwise substantially impacted by the programs, policies, and operations of the employee's agency, and the employee normally
would be involved personally and substantially in such matters on a frequent basis or as a principal duty. In addition, an activity may be improper if the
circumstances suggest that the employee received an outside business opportunity based on his or her official position or would create the appearance of
using public office for the private gain of an outside entity. An employee also must endeavor to avoid any actions that create the appearance of a violation of
law or the ethical standards. Special rules apply to activities involving fundraising, expert witness testimony, teaching, speaking, writing, or editing, and
activities with foreign entities. Certain categories of employees, such as those in FDA, NIH, and OGC, are subject to component specific rules on outside
activities. Refer to the Standards of Ethical Conduct, 5 CFR part 2635, subpart H, and the HHS Supplemental Ethics Regulation, 5 CFR part 5501.
2. Supervisor's Statement
Describe the extent to which the employee's official duties are related to the proposed outside activity.
3. Recommendation
The undersigned supervisor, identified in Part I, Item 10, has reviewed the employee's responses, obtained additional information where appropriate,
and recommends the following action:
Recommend Approval
If this box is checked, the supervisor understands that if the outside activity is approved, the employee may be disqualified from performing official
duties that involve or affect any outside entity with which the employee has an outside employment, consulting, or similar relationship. If the
activity constitutes employment or service as an officer, director, or trustee, or in another fiduciary role, the recusal obligation may extend not only
to government matters that specifically involve or affect the outside entity, but to those matters that affect generally the industry or economic
sector in which the outside entity operates. The supervisor concludes that any work assignments involving specific or general matters from which
the employee will be recused can be reassigned to another individual and are not so central or critical to the performance of the employee's
official duties that the employee's ability to perform the duties of his her position would be materially impaired.
Recommend Disapproval
If this box is checked, explain the reason(s) in the additional space provided on the last page of this form.
SUPERVISOR SIGNATURE
DATE
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PAGE 7 OF 16
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V. MANAGEMENT / COMMITTEE / OTHER INTERMEDIATE REVIEW
1. Name of Reviewer 2. Title of Reviewer
3. Reviewer Contact Information
TELEPHONE FAX
CELL EMAIL
4. Organization
5. Committee
If the reviewer acts on behalf of a committee, identify the body and record any dissenting views in the "Comments" below.
6. Review
Review the employee's answers and indicate whether you concur in the supervisor's recommendation. Explain your reason(s) in the space below. Sign
and date the form in the space provided.
Concur
Nonconcur
REVIEWER SIGNATURE DATE
7. Comments
HHS-520 (1/06) (Previous Editions Obsolete)
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VI. AGENCY ETHICS OFFICIAL REVIEW
1. Name of Agency Ethics Official
2. Title of Agency Ethics Official
3. Agency Ethics Official Contact Information
TELEPHONE FAX
CELL EMAIL
4. Organization
5. Ethics Review
Review the employee's answers and the supervisor's recommendation. Consider the assessment of any management official, committee, or other
intermediate reviewer. Based on the information provided and applying the standard for approval prescribed in 5 CFR 5501.106(d)(4), indicate whether
the activity can be approved or permission must be denied. Explain your reason(s) in the space below and describe any actions deemed necessary to
ensure compliance with applicable ethics laws. Sign and date the form in the space provided.
Request as described may be approved
Request may be approved subject to conditions noted in Comments Section
Request as described must be denied
Other disposition noted in Comments Section
AGENCY ETHICS OFFICIAL SIGNATURE DATE
6. Comments
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 9 OF 16
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VII. AGENCY DESIGNEE (APPROVING OFFICIAL) DETERMINATION
1. Name of Agency Designee
2. Title of Agency Designee
TELEPHONE
3. Agency Designee Contact Information
FAX
CELL EMAIL
4. Organization
5. Decision
Based on the foregoing statements and any supporting documentation, the recommendations of the supervisor and, if applicable, any management
official, committee, or other intermediate reviewer, and the review by the agency ethics official, the disposition indicated below constitutes my written
determination, pursuant to 5 CFR 2635.803 and 5 CFR 5501.106(d), that the request to engage in the identified outside activity is:
Approved
Approved subject to conditions
Denied
AGENCY DESIGNEE (APPROVING OFFICIAL) SIGNATURE DATE
6. Specified Conditions (if any)
7. Comments
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 10 OF 16
VIII. NOTICES
APPROVAL OF AN OUTSIDE ACTIVITY DOES NOT RELEASE YOU FROM A CONTINUING LEGAL OBLIGATION TO
DISQUALIFY YOURSELF FROM OFFICIAL ASSIGNMENTS AFFECTING YOUR OUTSIDE EMPLOYER OR THE ENTITY
TO WHICH YOU ARE PROVIDING PERSONAL SERVICES. WHILE PERFORMING AN APPROVED OUTSIDE
ACTIVITY, ANY ACTIONS TAKEN IN CONFLICT WITH APPLICABLE ETHICS LAWS MAY SUBJECT YOU TO
CRIMINAL PROSECUTION OR DISCIPLINARY PROCEEDINGS.
Caution. When you consult, teach, speak, write, serve on a board,
or work for a company, organization, or other entity outside your
government job, your relationship with that outside entity has certain
legal and ethical consequences. The approval of an outside activity
does not mean that you are free of conflicts of interest. You must
still follow all substantive ethics requirements after approval is
granted. Consult the ethics regulations at 5 CFR 2635.802 and
5501.106(d)(4) which are reprinted below.
Conflicts Resolution. An approved HHS Form 520 does not
signify that you need not be concerned about conflicts of interest.
Under the law, conflicts of interest arising out of outside employment
or service in a fiduciary position can be resolved in advance in only
three ways: (1) you can inform your supervisor and disqualify
yourself from participating in a conflicting government matter (often
called a recusal); (2) you can seek, if certain legal requirements are
satisfied, a separate legal document from your appointing official or
designee that specifically permits you to work on the government
matter (known as a waiver), or (3) you can resign from either your
government or outside job. Outside relationships that fall short of
actual employment or a fiduciary role pose similar appearance
concerns that must be addressed under procedures in 5 CFR
2635.502.
Effect of Prior Approval. The outside activities prior approval
process has very limited purposes. When a reviewer approves an
HHS Form 520 for your outside activity, two fundamental
assessments are being made, which are discussed below. You
reasonably may rely on these specific determinations only if you
provided all relevant information on the form and the
circumstances under review do not thereafter
change. You remain
responsible for the legal and ethical consequences of any change
in personal or business affairs or a change in your government
duties.
First, based on the information which you provide, the reviewer
determines whether your proposed activity is plainly prohibited by
applicable statutes or regulations, including the provisions of the
ethical standards governing appearances of impropriety. For
example, if you want to lobby Federal agencies on behalf of a non-
profit organization that employs you, prior approval will be denied
because a cr
iminal statute prohibits such representational
activities.
Second, assuming your proposed activity is not specifically
prohibited, the reviewer determines whether, under the circum-
stances, approval should be denied for other reasons specified
under the law. For example, the reviewer may deny approval if the
facts show that you used your government position to obtain an
outside compensated business opportunity or if the activity would
create the appearance that you are violating the law or the ethical
standards. Another common reason for denying approval is that the
outside activity may prevent you from handling work that is expected
of you. Because the outside activity may cause you to have to
disqualify yourself from a broad range of job assignments, or even a
few crucial projects, that will affect your outside employer or the
entity to which you provide personal services, it may be impossible
for you to discharge fully your government duties.
If, however, your outside activity is approved, the reviewer has
determined that the matters in which you will not be allowed to
participate are not “so central or critical to the performance of [your]
official duties” that your ability to perform the duties of your position
would be materially impaired. In other words, you cannot work on a
government matter affecting your outside employer, but the
reviewer expects that you will be able to stay away from these
assignments and still do your job.
Recusal Obligations. When performing your Federal duties, you
must not participate in any government matter that will affect your
own self-interest in continuing your outside job or activity. For
example, you would have to disqualify yourself from participating in
any official matter that might put your outside employer out of
business or seriously affect its finances, either positively or
negatively, so that the odds of your remaining employed are also
affected. In addition, when you work for an outside employer or
serve in a fiduciary role with an organization, the financial interests
of that company or organization are considered to be your own. As
a result, if the company or organization has a financial interest in
how a government matter will be resolved, you cannot work on that
matter. This means that you cannot work on a government matter
that involves or affects your outside employer as a specific party,
such as a contract, grant, audit, investigation, or litigation. The law
also requires you to stay away from government matters that are
larger in scope, such as deliberations and decisions on developing,
implementing, or enforcing statutes, regulations, policies, studies,
or proposals, that will have an effect on a large class of employers
like the one for which you work on the outside. For example, if you
were permitted to have an outside position as an employee of a
hospital, a drug company, or a nonprofit organization, you could not
participate personally in any significant way in a policy decision that
affects the financial interests of the industry or organizational sector
in which these employers operate. Under certain limited
circumstances, a waiver for such “particular matters of general
applicability” can be considered, if you notify your appointing official
in advance and receive a written determination. Outside relation-
ships that fall short of actual employment or a fiduciary role pose
similar appearance concerns, but the recusal obligation is limited to
specific party matters.
Scope of Recusal. Although many employees understand the
need to disqualify themselves from participating in an official matter
that affects their outside employer, they often believe erroneously
that they can pick and choose among the various aspects of a
particular matter and stay away only from the important decisions.
Such incomplete recusals will not protect you from a criminal
conflict of interest violation. Unless a waiver, approved in advance,
identifies specific permitted activities, you must refrain entirely and
absolutely from participating personally and substantially in a
government matter that affects your own financial interest or that of
an outside employer. When you are involved significantly in
proposing, planning, advising, deciding, or implementing some
official action, and you do so individually or by actively directing
subordinates, your participation is personal and substantial.
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 11 OF 16
VIII. NOTICES (continued)
EXCERPTS FROM THE STANDARDS OF ETHICAL CONDUCT FOR EMPLOYEES OF THE EXECUTIVE BRANCH AND
THE DEPARTMENT OF HEALTH AND HUMAN SERVICES SUPPLEMENTAL AGENCY ETHICS REGULATIONS:
TITLE 5 CODE OF FEDERAL REGULATIONS
§ 2635.802 Conflicting outside employment and activities.
An employee shall not engage in outside employment or any other
outside activity that conflicts with his official duties. An activity
conflicts with an employee's official duties:
(a) If it is prohibited by statute or by an agency supplemental
regulation; or
(b) If, under the standards set forth in §§ 2635.402 and 2635.502, it
would require the employee's disqualification from matters so
central or critical to the performance of his official duties that the
employee's ability to perform the duties of his position would be
materially impaired.
Employees are cautioned that even though an outside activity may
not be prohibited under this section, it may violate other principles
or standards set forth in this part or require the employee to
disqualify himself from participation in certain particular matters
under either subpart D or subpart E of this part.
Example 1: An employee of the Environmental Protection Agency
has just been promoted. His principal duty in his new position is to
write regulations relating to the disposal of hazardous waste. The
employee may not continue to serve as president of a nonprofit
environmental organization that routinely submits comments on
such regulations. His service as an officer would require his
disqualification from duties critical to the performance of his official
duties on a basis so frequent as to materially impair his ability to
perform the duties of his position.
Example 2: An employee of the Occupational Safety and Health
Administration who was and is expected again to be instrumental in
formulating new OSHA safety standards applicable to manu-
facturers that use chemical solvents has been offered a consulting
contract to provide advice to an affected company in restructuring
its manufacturing operations to comply with the OSHA standards.
The employee should not enter into the consulting arrangement
even though he is not currently working on OSHA standards
affecting this industry and his consulting contract can be expected
to be completed before he again works on such standards. Even
though the consulting arrangement would not be a conflicting
activity within the meaning of § 2635.802, it would create an
appearance that the employee had used his official position to
obtain the compensated outside business opportunity and it would
create the further appearance of using his public office for the
private gain of the manufacturer.
§ 5501.106(d)(5) Standard for approval.
Approval shall be granted only upon a determination that the
outside employment or other outside activity is not expected to
involve conduct prohibited by statute or Federal regulation,
including 5 CFR part 2635 and this part.
Note: The granting of approval for an outside activity does not
relieve the employee of the obligation to abide by all
applicable laws governing employee conduct nor does
approval constitute a sanction of any violation. Approval
involves an assessment that the general activity as described
on the submission does not appear likely to violate any
criminal statutes or other ethics rules. Employees are
reminded that during the course of an otherwise approvable
activity, situations may arise, or actions may be contemplated,
that, nevertheless, pose ethical concerns.
Example 1: A clerical employee with a degree in library science
volunteers to work on the acquisitions committee at a local public
library. Serving on a panel that renders advice to a non-Federal
entity is subject to prior approval. Because recommending books
for the library collection normally would not pose a conflict with the
typing duties assigned the employee, the request would be
approved.
Example 2: While serving on the library acquisitions committee,
the clerical employee in the preceding example is asked to help the
library business office locate a missing book order. Shipment of the
order is delayed because the publisher has declared bankruptcy
and its assets, including inventory in the warehouse, have been
frozen to satisfy the claims of the Internal Revenue Service and
other creditors. The employee may not contact the Federal
bankruptcy trustee to seek, on behalf of the public library, the
release of the books. Even though the employee's service on the
acquisitions committee had been approved, a criminal statute, 18
U.S.C. 205, would preclude any representation by a Federal
employee of an outside entity before a Federal court or agency with
respect to a matter in which the United States is a party or has a
direct and substantial interest.
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 12 OF 16
PRIVACY ACT STATEMENT
The Ethics in Government Act, 5 U.S.C. App. § 101, et seq., Executive Order 12674, as amended by Executive Order 12731,
Sections 301 and 7301 of Title 5 of the U.S. Code, and Sections 2635.803 and 5501.106(d) of Title 5 of the Code of Federal
Regulations authorize the collection of this information. Disclosure of this information is mandatory for employees seeking prior
authorization from an agency designee to pursue outside employment or activities pursuant to Sections 2635.803 and
5501.106(d) of Title 5 of the Code of Federal Regulations. Failure to provide all or part of the requested information may result
in denial of the request for approval of the outside employment or activity. Falsification of information or failure to file or report
information required to be reported may subject the employee to disciplinary action. Knowing and willful falsification of
information required to be reported may subject the employee to criminal prosecution. The primary use of this information is to
allow HHS supervisors, management officials, and agency ethics officials to make necessary determinations concerning
employee requests for prior approval of outside employment or activities in order to prevent a conflict of interest or other
violations of the statutes, regulations, and executive orders governing employee conduct. The information is also requested,
pursuant to 5 C.F.R. §§ 2638.203(b)(9),(10), and (11), for the purpose of evaluating ethics program administration, as well as
the Department’s supplemental ethics regulations, to determine their continued adequacy and effectiveness in relation to
current agency responsibilities and to ensure that prompt and effective action is taken to remedy violations or potential
violations, or appearances thereof, of conflict of interest and related ethics provisions. Additionally, this information may be
disclosed to: (1) the Office of Personnel Management, Office of Government Ethics, Merit Systems Protection Board, Office of
the Special Counsel, Equal Employment Opportunity Commission, Federal Labor Relations Authority, Federal Service
Impasses Panel, Federal Mediation and Conciliation Service, and an arbitrator, in carrying out their functions; (2) a Federal,
State, or local agency charged with investigating or prosecuting violations of, or implementing, the law, in the event there is an
indication of a violation or potential violation of civil, criminal or regulatory law; (3) a Federal, State, or local agency maintaining
enforcement records or other pertinent records, such as current licenses, if necessary to obtain a record relevant to an agency
decision concerning the hiring or retention of an employee, the
issuance of a security clearance, the letting of a contract, or the
issuance of a license, grant or other benefit; (4) the National Archives and Records Administration or the General Services
Administration in records management inspections; (5) the Office of Management and Budget during legislative coordination
on privacy relief legislation; (6) Federal agencies with power to subpoena other Federal agencies’ records; (7) a court or party
in a court or Federal administrative proceeding if the Government is a party or in order to comply with a judge-issued
subpoena; (8) private firms with which the Department may contract for the purpose of collating, analyzing, aggregating or
otherwise refining records; (9) a Member of Congress or a Congressional office, pursuant to an inquiry made at the request of
the individual who is a subject of the record; (10) the Department of Justice in defense of litigation; and (11) contractors and
other non-Government employees working for the Federal Government to accomplish a function related to an Office of
Government Ethics Government-wide system of records. This confidential report will not be disclosed to any requesting person
unless authorized by law. See the OGE/GOVT-2 Government-wide executive branch system of records.
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 13 OF 16
STAPLE ATTACHMENTS TO THIS PAGE
List each attachment in the space provided and append copies.
1.
2.
4.
3.
5.
6.
7.
8.
9.
10.
HHS-520 (1/06) (Previous Editions Obsolete)
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ADDITIONAL SPACE
Identify the part and item number to which the additional information refers.
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 15 OF 16
ADDITIONAL SPACE (continued)
Identify the part and item number to which the additional information refers.
Department of Health and Human Services
Office of the Secretary
Office of the General Counsel
Ethics Division
Washington, DC 20201
(202) 690-7258
HHS-520 (1/06) (Previous Editions Obsolete)
PAGE 16 OF 16
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