A23 Attachment 7 - Contractor CIO Disclosure Form.docx

ADAP Form 209-506-1 Contractor Conflict of Interest Disclosure Form (AUG 2024)

1. WHS Solicitation or Contract Number:

2. Program Supported:

3. Organization name and address (if the conflict is with a Subcontractor, please provide their name and POC as well):

4. POC & Telephone:

5. Description of Work:

6. Is there an actual or potential conflict of interest? ___ NO ___ YES If yes, please provide the following information: Solicitation or Contract or Subcontract Number for Potential Conflict of Interest, Contract Number, Program Name, Project Name, Period of Performance, and Contract Value

7. Description of work performed under Block 6 action:

8. Relationship between requirements of Block 1 and the work performed under Block 6:

9. Organizational Conflict of Interest Evaluation and Assessment.

Describe the actual or potential conflict of interest. (Attach a copy of the SOW for the Block 6 and complete Block 10).

10. Summary of actions planned to avoid, neutralize, or mitigate the actual or potential conflict:

11. Personal Conflict of Interest Mitigation Plan.

In the event that a personal conflict of interest is identified, describe the conflict and provide a mitigation plan.

12. Typed Name of Responsible Official

13. Signature

14. Date

INSTRUCTIONS FOR COMPLETING THIS FORM

All Blocks: Please be as specific as possible, citing the specific RFP/SOW paragraph, etc. Please include subcontractors in any conflict analysis.

Block 6: Please mark an “X” to state whether an actual or potential conflict of interest exists. If answering “No,” then the contractor will not answer the remaining questions but will complete boxes 12 – 14. If answering “yes,” then provide the requested information in Block 6. NOTE: One Contractor Conflict of Interest Disclosure Form shall be submitted for EACH related solicitation, contract, or subcontract.

Block 7: Provide a brief, but specific, narrative summary of the SOW and work performed on the contract or subcontract listed in Block 6, including the period of performance and the value.

Block 8: Provide a brief, but specific, narrative summary of ANY relationship between the work to be performed under the action listed in Block 1 and the previous work performed under the action listed in Block 6.

Block 11: The contractor shall review and analyze potential personal conflicts of interest of employees to determine whether an actual or potential personal conflict of interest exists. Information should be gathered and analyzed for all governing body members (e.g., board of directors, trustees, etc.) and principals of the organization as defined by FAR 52.203-13 and for each manager and key personnel who would be, or are involved, with the performance of the contract.

To assist in the identification and analysis, the contractor should consider the following, at a minimum, in determining if personal conflicts of interest are present.

• Assets, sources of income, outside positions, etc. for self, spouse/domestic partner, and any dependent(s);

• Assets and healthcare related income arrangements or agreements to include healthcare related stock, bond, sector fund, employer or business fees, commissions, honoraria, real estate investment, for self, spouse/domestic partner, and any dependent(s);

• Liabilities for self, spouse/domestic partner, and any dependent(s); and

• Non-employer healthcare travel-related reimbursements or gifts.

Block 12 and 13: Provide the name of your company official with the responsibility for and authority to discuss and commit the company on matters related to OCI issues. That official should then sign and date each form.