APPVD COI April 2018 B-248 Audio Technical COIR.pdf

PPB COIRR 160225 V10

CONFLICT OF INTEREST REVIEW AND DETERMINATION

If a vendor or subcontractor discloses any of the relationships identified in Section 50‐35(b) of the Procurement Code, the Agency/University must complete this form and submit it to the assigned SPO for further action, which may include forwarding the form to the CPO or the PPB.

Sections I‐V must be completed by the Agency/University and must not have any blank responses; if a question is not applicable, complete by stating “N/A”.

SECTION I ‐ AGENCY/UNIVERSITY REQUESTING THE REVIEW

Using Agency/University:

Contact Person: Title:

Phone: Email:

SECTION II – VENDOR/SUBCONTRACTOR INFORMATION NEEDING REVIEW

Name of Vendor/Subcontractor:

Contact Person: Title:

Phone: Email:

SECTION III – PROPOSED CONTRACT INFORMATION

Describe the proposed contract:

Procurement Bulletin Reference Number: Date Award Posted to Bulletin:

This is the: Initial Contract Renewal Contract Number:

Contract/Renewal Estimated Start Date: Contract/Renewal Estimated End Date:

Describe future renewal options (i.e. 1 two‐year option):

Total Contract/Renewal Amount: $ Value is: Actual Estimated

The entity with the potential conflict of interest is the: Prime or Awarded Vendor Subcontractor Subcontractor of:

Parent Parent of:

If this is a conflict of interest review for a subcontractor, what is the estimated value of the subcontract? $

What was the original method of procurement used to select this vendor (RFP, IFB, Small Purchase, Sole Source, Emergency, etc.)?

SECTION IV ‐ EXPLANATION OF POTENTIAL CONFLICTS OF INTEREST

1. Provide the following information for EACH individual identified as having any of the relationships identified in Section 50‐35 (b) of the Procurement Code:

Name of individual:

Describe the Relationship(s) identified in Form A Step 5 or Form B IPG Form I questions 11‐20:

Does the relationship disclosed involve an Agency/University State employee: Yes No

If Yes, complete the following:

Start date:

Job title and responsibilities:

Individual’s annual salary: $ Was this individual in a position to influence the State’s award of this contract? Yes No

2. Explain the potential or actual conflict of interest:

3. Why is it in the best interest of the agency/university to contract with this vendor despite the potential or actual conflict of interest?

4. Has the PPB previously reviewed the potential conflict of interest in the current fiscal year and recommended no further action?

Yes No

If yes, describe any change in circumstance and how that might result in a different ruling.

5. What is the funding source for this contract? (check all that apply) Federal Funds State Appropriated Funds Other (Explain):

SECTION V – AGENCY/UNIVERSITY REPRESENTATIVE CHECKLIST AND SIGNATURE

The following documents are included with this request to the SPO:

Copy of Agency/University Internal Approval or waiver of the conflict Completed and Signed Conflict of Interest Review and Determination Form Copy of Proposed Contract (may be the proposed contract sent in with a RFP response, a copy of the solicitation response, etc.)

Copy of the Disclosure/Certification Documents Submitted by the Vendor Prior Procurement Policy Board Conflict of Interest Review Letter for this Vendor

Additional information:

As authorized representative of the Agency/University, I do not view the relationship disclosed above as creating a potential for a conflict of interest based on the circumstance and accordingly request authorization to proceed with the contract.

As authorized representative of the Agency/University, I am submitting this information for review in order to determine whether there is a potential for a conflict based on the described circumstance, and request authorization to proceed with the contract for the reasons stated above.

Agency/University Representative Signature Agency/University Representative Title Date

Agency/University Representative Printed Name Email Address Telephone

SECTION VI – STATE PURCHASING OFFICER REVIEW AND SIGNATURE

I do not view the relationship disclosed above as creating a potential for a conflict of interest. The disclosed relationship does not preclude the Agency/University from entering into the proposed contract for the supplies or services outlined in this form.

[SPO to send signed form to the Agency/University—no referral to CPO or PPB necessary]

I find the request and justification is not sufficiently clear and needs CPO review and determination whether the disclosed information presents a potential for a conflict of interest. [SPO to forward material to CPO]

I find a potential for a conflict of interest and refer this request to the PPB for review and recommendation. All relationships disclosed under 50‐35(b)(1) or (b)(2) are considered as presenting a potential for a conflict. [SPO to scan and email signed copies (keep originals) to: matthew.vonbehren@illinois.gov with cc: to deanna.rossetto@illinois.gov and tonya.wallace@illinois.gov.]

Additional comments:

SPO Signature SPO Printed Name Date

Email Address Telephone

SECTION VII– CHIEF PROCUREMENT OFFICER REVIEW AND SIGNATURE (required if SPO refers to CPO for further review)

After considering the material provided, I do not view the relationship disclosed above as creating a potential for a conflict of interest. The disclosed relationship does not preclude the Agency/University from entering into the proposed contract.

[CPO to send signed form to SPO for distribution to the Agency/University]

After considering the material provided, I find a potential for a conflict of interest and refer this request to the PPB for review and recommendation. The Agency/University may not enter into the proposed contract pending recommendation of the PPB and subsequent final determination by the CPO.

[CPO to scan and email signed copies (not originals) of material provided to the PPB.]

Additional comments:

CPO Signature CPO Printed Name Date

SECTION VIII – PROCUREMENT POLICY BOARD REVIEW AND SIGNATURE

(required only if SPO/CPO refers to PPB for further review)

After careful review of the documentation provided, I do not view the relationship disclosed above as creating a conflict of interest sufficient to preclude the Agency/University from entering into the proposed contract.

After careful review of the documentation provided, I view the relationship disclosed above as creating a conflict of interest sufficient to preclude the Agency/University from entering into the proposed contract. The detailed reasons are shown on the attached Recommendation of the Procurement Policy Board. This recommendation shall be forwarded to the Executive Ethics Commission in accordance with Section 50‐35(d) of the Procurement Code.

Procurement Policy Board Signature Procurement Policy Board Printed Name Date