State of California—Health and Human Services Agency Department of Health Care Services
DHCS 2415 (10/19)
TRA
INING CERTIFICATION
FOR CONFLICT OF INTEREST ETHICS COURSES
I understand that because I am required to file a Form 700, I am also required to complete two
approved Conflict of Interest ethics courses, one offered by the Office of the Attorney General and the
other offered by the Department. These training courses must be repeated every two calendar
years.
Provide original of completed form to your immediate supervisor and retain a
copy for your records. Supervisors must retain the original certification form
for a period of not less than five (5) years following the date the training
course was completed.
I hereby certify that I have completed the self-study course(s) marked below:
Name:
(type or print)
P
lease indicate the course(s) you have
completed and sign below:
Classification:
Ethics 1—Ethics Orientation
(Department of Justice)
Telephone number:
( ) -
Date completed:
/ /
Section:
Ethics 2—Ethics Orientation
(Department of Health Services)
Branch:
Date completed:
/
/
Division:
Office address:
MS code:
City:
ZIP
code:
Your signature:
