4-Form 2b Conflict of Interest Certification UGE.pdf
PDF 167 KB Posted
- Attached to
- Optometry Services at USH
- Solicitation number
- DHHS26051
- Issued by
- Utah
About this file
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 or its divisions. The certification establishes that the governmental entity is a political subdivision, agency, or municipality of Utah that has either contracted with DHHS or entered into a subcontract with a local agency holding a DHHS contract. The form applies specifically to the Optometry Services at Utah State Hospital contract opportunity, which involves providing optometry services to USH patients.
The certification requires the governmental entity to maintain a written conflict of interest disclosure policy applicable to all Representatives, defined as any person or entity acting on behalf of the contractor, including employees, owners, partners, directors, officers, board members, subcontractors, and agents with authority to establish policies or make decisions. The entity must monitor operations for compliance and ensure that Representatives with potential conflicts of interest do not make or influence decisions affecting the DHHS contract, monitor contract performance, or benefit from contract performance. Volunteers are excluded from disclosure requirements unless they serve as board members, officers, or are substantially involved in decision-making processes.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 3-Form 1 IRS Form W-9.pdf | ||
| 6-Form 2a Conflict of Interest Disclosure Statement.pdf | ||
| 1-DHHS26051 IFB Optometry Services at USH.docx | DOCX document | |
| 5-DHHS26051 Cost Proposal Form.doc | DOC document | |
| 8-DHHS26051 Submission Instructions.docx | DOCX document | |
| 7-DHHS Client Service Terms.docx | DOCX document | |
| 2-DHHS26051 Optometry Services SOW Final.docx | DOCX document |
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Text version
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 .