5-Form 2b Conflict of Interest Certification UGE.pdf

167 KB Posted

Attached to
Optometry Services at Utah State Hospital
Solicitation number
DHHS26065
Issued by
Salt Lake County, Salt Lake City, 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 for entities entering into or applying for contracts with DHHS or its divisions and offices. The certification applies to the Optometry Services contract at Utah State Hospital and requires the governmental entity to confirm it 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 entity must maintain a written conflict of interest disclosure policy applicable to all representatives, including employees, owners, partners, directors, officers, board members, subcontractors, and agents with authority to establish policies or make decisions, though volunteers are exempt unless they serve as board members, officers, or are substantially involved in decision-making processes.

The governmental entity must monitor its operations for compliance with conflict of interest provisions and provide reasonable assurance that representatives with potential conflicts of interest shall not make or influence decisions affecting the contract, monitor contract performance, or benefit from contract performance. The form requires certification signatures from authorized representatives of the governmental entity and must be completed and submitted as part of the contract application or execution process. No pricing terms, set-asides, incumbents, or funding information is contained in this certification document.

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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 .