5-Form 2a Conflict of Interest Disclosure Statement.pdf

Conflict of Interest Disclosure Statement Page 1 of 2 Revised: 6/17/2022

State of Utah Department of Health and Human Services

Conflict of Interest Disclosure Statement

“Conflict of Interest” means any situation where the vendor has economic, social, political, familial, legal or other interests which will interfere with, or have the potential to interfere with, the exercise of the vendor’s duties, responsibilities, or judgment in connection with a contract, or which involve conflicting loyalties to the vendor and to another interest. “Conflict of Interest” also includes any violation of the Ethics Acts (Utah Code § 67-16-1 et seq. and § 10-3-1301 et seq.). Conflicts of Interest can occur in one of three ways:

(1) Dual Employment. Conflicts of interest can occur when a vendor’s representative is also employed by the State of Utah or by another vendor's representatives.

(2) Related-Party Transactions. Conflicts of interest occur when the vendor makes payments to a related party using money obtained from DHHS through this Contract. Conflicts of interest also occur when transactions, which affect the performance of this Contract, are made between the vendor and a related party, whether or not payments are involved. “Related Party” means:

(a) any person related to the vendor’s representative by blood or marriage including father, mother, husband, wife, son, daughter, sister, brother, grandfather, grandmother, mother-in-law, father-in-law, brother-in-law, sister-in-law, son-in-law, daughter-in-law, uncle, aunt, nephew, niece, grandson, granddaughter, or first cousin; and

(b) all business associates of the vendor: (i) who are partners, directors, or officers in the same business entity as the vendor; (ii) who have authority to make decisions or establish policies in the same business entity as the vendor; or (iii) who directly or indirectly own 10% or more in the same business entity as the vendor.

(3) Independent Judgment Impaired. Conflicts of interest occur when a vendor’s representative participates in any transaction on the vendor’s behalf and has a significant relationship or shared interest with another party to the transaction, which could affect the representative’s ability or willingness to exercise independent judgment, and which may affect the performance of this Contract. Independent judgment may also be impaired when the vendor or the vendor's representative is involved in any administrative or legal action pending against the State, DHHS, or any of their officers or employees.

“Representative” means any person or entity acting on behalf of the vendor, 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 vendor. “Volunteers” are not “representatives” and are not required to be included in the vendor’s Disclosure Statement, unless they are board members or officers, or are substantially involved in the vendor's decision-making processes.

“Vendor” includes contractors and all Representatives of the vendor.

By submitting a Disclosure Statement, the vendor is certifying to DHHS that it has checked its organization and has required its representatives to disclose their conflicts of interest, and that it has disclosed all known conflicts of interest to DHHS.

The vendor and its subcontractors have a continuing duty to immediately review updated Disclosure Statements and submit a copy to DHHS whenever an existing or potential Conflict of Interest is disclosed. The vendor shall require its subcontractors to provide an updated Disclosure Statement to the vendor, if at any time they contemplate any transaction involving a potential conflict of interest, hire or affiliate with any individual with an existing or potential conflict of interest, or discover any existing conflict of interest.

Conflict of Interest Disclosure Statement Page 2 of 2 Revised: 6/17/2022

State of Utah Department of Health and Human Services Conflict of Interest Disclosure Statement

Instructions: Use a separate form for each employee with a conflict or potential conflict, and complete all applicable sections of the form. Typed responses are preferred.

Contractor/Vendor Legal Name:

Does an employee in your organization have a conflict of interest or potential conflict of interest? Yes ☐No ☐

☐ Dual Employment Name of person with dual employment:

Title or position with the State of Utah:

Title or position with the contractor/vendor:

Nature and value of the individual’s interest in contractor/vendor’s business:

Individual’s decision making authority with the contractor/vendor and with the State:

How does the vendor protect DHHS from potentially adverse effects resulting from this individual’s conflict?

☐ Related-Party Transactions or Independent Judgment Impaired Name and position or title of individual associated with contractor/vendor:

Name and position or title of individual associated with other party:

Relationship between identified individuals:

Description of transaction involving identified individuals and dollar amount (if any):

Decision-making authority of individuals with respect to that transaction:

Potential effect on contract with DHHS:

How does the contractor/vendor protect DHHS from potentially adverse effects resulting from this identified conflict?

By submitting this form I certify that the information I have given is true and complete to the best of my knowledge.

Name and Title of Person Completing Form Date

For DHHS Use Only

Approve ☐ Deny ☐ Reviewer Name and Division Date

“Approve” means the agency has no reason to question the accuracy of a “no conflicts” declaration or the agency has taken sufficient action to determine the facts declared by the contractor/vendor do not constitute a prohibited conflict of interest.