4-DHHS25038 Attachment C (b) Conflict of Interest Certification UGE.pdf

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Attached to
Audiology Services
Solicitation number
DHHS25038
Issued by
Utah

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This is a Governmental Entity Conflict of Interest Certification form issued by the State of Utah Department of Health and Human Services (DHHS) for use by governmental entities entering into or applying for contracts with DHHS divisions or offices, or subcontracting with local agencies holding DHHS contracts. The certification requires governmental entities to confirm they are political subdivisions, agencies, or municipalities of the State of Utah and that they maintain written policies requiring their Representatives—defined broadly to include employees, owners, partners, directors, officers, board members, subcontractors, and agents with decision-making authority—to disclose conflicts of interest. The form establishes the entity's commitment to monitoring compliance with conflict of interest provisions and ensuring that Representatives with potential conflicts do not make or influence decisions affecting DHHS contracts, monitor contract performance, or benefit from contract performance.

The certification form contains signature lines for authorized representatives of both the governmental entity and DHHS, with space for entity name, address, city, state, and zip code. The form was revised on July 12, 2023, and serves as a standardized compliance document applicable to the Audiology Services contract opportunity with Utah State Correctional Facility and Central Utah Correctional Facility. Notably, the form excludes volunteers from Representative disclosure requirements unless they serve as board members, officers, or are substantially involved in the contractor's decision-making processes.

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Other files

File Type Posted
8-DHHS25038 Attachment F Score Sheet.xlsx XLSX spreadsheet
10-DHHS25038 Attachment E Technical Response.docx DOCX document
6-DHHS25038 Attachment B Scope of Work.docx DOCX document
2-DHHS25038 Attachment H Submission Checklist.docx DOCX document
1-DHHS25038 Attachment A DHHS Client Service Terms.docx DOCX document
9-DHHS25038 Attachment G Cost Proposal Sheet.xlsx XLSX spreadsheet
5-DHHS25038 Attachment C (a) Conflict of Interest Form.pdf PDF
11-DHHS25038 Attachment I CHS Addendum.docx DOCX document
7-DHHS25038 Request for Proposal.docx DOCX document
3-DHHS25038 Attachment D W9.pdf PDF

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Gov’t Entity Conflict of Interest Certification Page 1 of 1 Revised 7/12/2023

State of Utah Department of Health and Human Services Governmental Entity Conflict of Interest Certification

Governmental Entity Name:

Address: City: State: Zip:

The governmental entity certifies that:

1. It is a political subdivision, agency, or municipality of the State of Utah;

2. It has either entered into, or applied for, a contract with the Department of Health and Human Services or one of the Department's divisions or offices ("DHHS") or it has entered into a subcontract with a local agency that has a contract with DHHS;

3. It maintains a written policy requiring its Representatives to disclose their conflicts of interest.

“Representative” means any person or entity acting on behalf of the contractor, and includes all employees, owners, partners, directors, officers, board members, subcontractors, and agents, as well as any individuals with authority to establish policies or make decisions for the contractor. Volunteers are not Representatives and are not required to be included in the contractor’s disclosure statement, unless they are board members or officers, or are substantially involved in the contractor's decision-making processes.

4. It will monitor its operations for compliance with the conflict of interest provisions in the DHHS contract, and it can reasonably assure DHHS that Representatives with a potential conflict of interest shall not:

a. make or influence decisions or set policies that affect the contract with DHHS or with a local agency;

b. monitor the performance of its contract with DHHS or with a local agency; or

c. become involved in or otherwise benefit from the performance of its contract with

DHHS or with a local agency.

Name: Date:

Title:

Governmental Entity Name:
Address:
City:
State:
Zip:
Name:
Date:
Title:

File details come from the government source that posted it. Updated .