2-Attachment G - Conflict Of Interest Analysis Form.pdf

ATTACHMENT G: CONFLICT OF INTEREST ANALYSIS FORM

RFO 701-26-021, OneSystem

The Texas Education Agency (TEA) will not accept information provided in other areas of the response in lieu of full completion of this form. TEA recommends this completed form and responsive attachments be incorporated into a separate and distinct section of the response. Failure to furnish this information will result in disqualification from further consideration. Attach additional pages if more space is needed to complete the form.

It is the policy of the State of Texas and TEA that a state officer or employee may not have a direct or indirect interest, including financial and other interest, or engage in a business transaction or professional activity, or incur an obligation of any nature that conflicts with the proper discharge of the officer or employee’s duties in the public interest (Texas Gov’t Code §572.001(a)). TEA is committed to vetting any conflict of interest or the appearance of any conflict of interest that may arise in the procurement process. TEA will use information in this document to review conflicts of interest or potential conflicts of interest for this procurement.

SECTION A: CONTRACTOR INFORMATION

1. List the members (names and titles) of the contractor’s board of directors, advisory council, or governing board. (If the contractor does not have a board of directors, advisory council, or governing board, then enter N/A.)

Name Title

2. List the contractor’s executive or senior leadership (names and titles). (If the contractor is a sole proprietor or does not have executive or senior leadership, then enter N/A.)

Name Title https://statutes.capitol.texas.gov/Docs/GV/htm/GV.572.htm

3. Complete the table below for any individual not already listed in 1. or 2. above who owns more than $25,000 of the fair market value of the contractor’s business entity, or holds shares, stocks, or other direct/indirect participation in more than 10% of profits, proceeds, or capital gains. (If not applicable, then enter N/A.)

Name Title Description of Business Interest

4. Attach the contractor’s organizational chart.

5. Attach resumes of all project leadership and proposed staff providing services as part of this response.

6. Complete the table below for current or former TEA officials or employees who are or have been employed by the contractor. (If the contractor has never employed a current or former TEA official or employee, then enter N/A.)

Name Employment Dates with TEA

Job Title/Function with TEA

Employment Dates with respondent

Job Title/Function with respondent

SECTION B: SUBCONTRACTOR AND SUPPLIER INFORMATION

1. Complete the table below for ALL proposed subcontractors and suppliers included in this response. (If the contractor will not subcontract any part of the proposed services or goods, then enter N/A and skip to Section C.)

Name Address Telephone Number

2. Attach organizational charts for all proposed subcontractors and suppliers in this response.

3. Attach resumes of all proposed subcontractor and supplier staff providing services or goods as part of this response.

4. Complete the table below for current or former TEA officials or employees who are or have been employed by proposed subcontractors or suppliers. (If the proposed subcontractors or suppliers have never employed a current or former TEA official or employee, then enter N/A.)

Name Employment Dates with TEA Job Title/Function with TEA

Employment Dates with subcontractor or supplier

Job Title/Function with subcontractor or supplier

SECTION C: GIFTS, DONATIONS, FAVORS, SERVICES, OR BENEFITS

1. Please list below any gift or donation the contractor, a proposed subcontractor, or a proposed supplier has offered to a TEA official or employee during the two calendar years before submitting a response to this solicitation. You are required to state the date the gift or donation was offered, provide a description of the gift or donation, and provide the monetary value. Indicate whether the value is an estimated or actual value. List the individual at TEA you corresponded with regarding the gift or donation. (If the contractor, proposed subcontractors, or proposed suppliers did not offer gifts or donations, then enter N/A.)

Date of Gift or Donation

Description of Gift or Donation Monetary Value (actual or estimated)

Agency Contact

2. Has the contractor or any proposed subcontractor or supplier requested a meeting with TEA senior officials in the past calendar year? (Senior official is defined as Commissioner, Deputy Commissioner, Associate Commissioner, and Executive Director.) If yes, list the date of meeting, the purpose of the meeting, and TEA senior official who attended. (If no meetings were requested, then enter N/A.)

Date of Meeting

Description TEA Senior Official

Please attach the following items here:

1. Contractor’s organizational chart.

2. Resumes of all project leadership and proposed staff providing services as part of this response.

3. Resumes of all proposed subcontractor and supplier staff providing services and/or products as part of this response.

Name and Title of Authorized Representative Completing Form:

Organization Name: