Statement Of Economic Interests - Form 700
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1State of California—Health and Human Services Agency
Department of Health Care Services
Statement of Economic Interests – Form 700
Supervisor Review Transmittal
This transmittal must be attached to every Form 700 submitted by DHCS employees, consultants, and
contract employees. Every Form 700 will be reviewed by a supervisor to identify potential conflicts of
interest between the work assignments of the employee, consultant, or contract employee and their
disclosed outside economic interest(s). If any interests are disclosed, the form must be reviewed by two
supervisory levels. The Office of Legal Services (OLS) is available to assist supervisors with questions
about potential conflicts of interest (916-440-7700). The attached Form 700 must be filed annually with
the Department’s Filing Officer in the Human Resources Branch (HRB) no later than April 1. Failure to
comply could result in criminal charges, fine(s) of $10,000 or more, and/or disciplinary action. Both
forms are to be filed with the Department Filing Officer in HRB, who will then forward to OLS for review.
PRINT EMPLOYEE NAME
DIVISION
POSITION NO. AND APPOINTMENT
TYPE (i.e., consultant, contractor)
______________________
________________
______________________________
I. First Line Supervisor Review (required). I have reviewed the attached Form 700.
Based upon my review and knowledge of the filer’s position, I have concluded that the Form
1
700 (check all that apply):
is complete
(required);
has an original signature (required);
No reportable interests are disclosed on any schedule (no further explanation required);
Reportable interests are disclosed on the following schedules:
A-1;
A-2;
B;
C;
D;
E. Please explain why the outside economic interest(s)
do(es) not constitute nor appear to constitute a conflict of interest (i.e. unrelated to DHCS business;
________________
unrelated to filer’s governmental decisions; interest immaterial; conflict mitigated):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I am unable to determine that the outside economic interest does not pose a conflict of
interest and request further review of this Form 700 because (i.e. outside employment closely related to
DHCS; business ownership closely related; unclear if gift is acceptable; conflict is suspected):
__________________________________________________________________________________
___________________________________________________________________________
First Line Supervisor Signature
Please Print Name
II. Second Line Supervisor Review (required if any reportable interests disclosed).
I have reviewed the attached Form 700 and I
agree
disagree with the First Line
Supervisor’s assessment. The basis of my opinion is: _______________________________
__________________________________________________________________________
I am requesting a review be completed by OLS. (Submit forms to HRB. HRB will route to OLS.)
Second Line Supervisor Signature
Please Print Name
1
Complete Form 700s must include all applicable schedules attached and all requested information provided.
DHCS 9048 (01/10) - Submit with original Form 700 to the Department Filing Officer in Human Resources Branch
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