5-DHHS26117 Attachment C (b) Conflict of Interest Certification UGE.pdf
PDF 167 KB Posted
- Attached to
- Mobile MRI and CT Services
- Solicitation number
- DHHS26117
- Issued by
- Salt Lake County, 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 contracts with DHHS or its divisions, or subcontracting with local agencies that hold DHHS contracts. The certification applies to the Mobile MRI and CT Services contract opportunity at Utah State Correctional Facility, which requires the provision of self-contained mobile Computed Tomography and Magnetic Resonance Imaging services. The form requires the contracting governmental entity to certify its status as a political subdivision, agency, or municipality of the State of Utah and to confirm that it maintains a written policy requiring all Representatives—defined as employees, owners, partners, directors, officers, board members, subcontractors, and agents with decision-making authority—to disclose conflicts of interest.
The certification obligates the governmental entity to monitor its operations for compliance with DHHS conflict of interest provisions and to ensure that Representatives with potential conflicts of interest do not make or influence decisions affecting the contract, monitor contract performance, or benefit from contract performance. The form, revised as of July 12, 2023, requires signatures from authorized representatives of the governmental entity and contains fields for entity name, address, signatory name, title, and date of certification. No pricing, funding amounts, set-asides, incumbent information, or contract term details are specified in this certification document.
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Other files
| File | Type | Posted |
|---|---|---|
| 4-DHHS26117 Attachment D W9.pdf | ||
| 8-DHHS26117 Attachment A Client Service Terms.docx | DOCX document | |
| 10-DHHS26117 Attachment E Technical Response.docx | DOCX document | |
| 9-DHHS26117 Request for Proposal.docx | DOCX document | |
| 6-DHHS26117 Attachment C (a) Conflict of Interest Form.pdf | ||
| 11-DHHS26117 Attachment G Cost Proposal Sheet.xlsx | XLSX spreadsheet | |
| 7-DHHS26117 Attachment B Scope of Review.docx | DOCX document | |
| 3-DHHS26117 Attachment I CHS Addendum.docx | DOCX document | |
| 2-DHHS26117 Attachment H Submission Checklist.docx | DOCX document | |
| 1-DHHS26117 Attachment F Score Sheet.xls | XLS spreadsheet |
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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 .