A02.12 PWS Exhibit A - COI Form IEPR Wilmington Harbor.DOCX

Conflicts of Interest Questionnaire Independent External Peer Review Independent External Peer Review (IEPR) for the Wilmington Harbor, North Carolina Study

The purpose of this document is to help the U.S. Army Corps of Engineers identify potential organizational conflicts of interest on a task order basis as early in the acquisition process as possible. Complete the questionnaire with background information and fully disclose relevant potential conflicts of interest. Substantial details are not necessary; USACE will examine additional information if appropriate. Affirmative answers will not disqualify your firm from this or future procurements.

NAME OF FIRM: _____________________________

REPRESENTATIVE’S NAME: _____________________________

TELEPHONE: ___________________

ADDRESS: __________________________________________________________

EMAIL ADDRESS: ___________________________________________________

I. INDEPENDENCE FROM WORK PRODUCT. Has your firm been involved in any aspect of the preparation of the subject study report and associated analyses (field studies, report writing, supporting research etc.) No Yes (if yes, briefly describe):

II. INTEREST IN STUDY AREA OR OUTCOME. Does your firm have any interests or holdings in the study area, or any stake in the outcome or recommendations of the study, or any affiliation with the local sponsor? No Yes (if yes, briefly describe):

III. REVIEWERS. Do you anticipate that all expert reviewers on this task order will be selected from outside your firm? No Yes (if no, briefly describe the difficulty in identifying outside reviewers):

IV. AFFILIATION WITH PARTIES THAT MAY BE INVOLVED WITH PROJECT IMPLEMENTATION. Do you anticipate that your firm will have any association with parties that may be involved with or benefit from future activities associated with this study, such as project construction? No Yes (if yes, briefly describe):

V. ADDITIONAL INFORMATION. Report relevant aspects of your firm’s background or present circumstances not addressed above that might reasonably be construed by others as affecting your firm’s judgment. Please include any information that may reasonably: impair your firm’s objectivity; skew the competition in favor of your firm; or allow your firm unequal access to nonpublic information.

YOUR SIGNATURE DATE