Attachment 0009_OCI Disclosure Form.docx

UNCLASSIFIED

ORGANIZATIONAL CONFLICTS OF INTEREST

ANALYSIS FORM

ORGANIZATIONAL CONFLICTS OF INTEREST (OCI) DISCLOSURE AND ANALYSIS FORM

SECTION I. REQUIREMENT FOR WHICH ANALYSIS IS BEING CONDUCTED

1. SOLICITATION/CONTRACT NUMBER

2. PROGRAM TITLE

5. TYPE OF WORK TO BE PERFORMED UNDER THIS SOLICITATION OR, IF AFTER AWARD, UNDER THIS CONTRACT (CHECK ALL THAT APPLY):

☐ (A) PROVIDING SYSTEMS ENGINEERING AND TECHNICAL DIRECTION

☐ (B) PREPARING SPECIFICATIONS OR WORK STATEMENTS

☐ (C) PROVIDING TECHNICAL EVALUATION OR ADVISORY & ASSISTANCE SERVICES

SECTION II. CONTRACTS AWARDED TO YOUR COMPANY REQUIRING COMPARISON TO WORK IN SECTION I

6A. OTHER NGA OR RELATED IC WORK REQUIRING—

7. BRIEF SUMMARY/DESCRIPTION OF WORK PERFORMED UNDER CONTRACT LISTED UNDER BLOCK 6A-6C:

8. RELATIONSHIP BETWEEN REQUIREMENTS OF BLOCK 1 ACTION AND WORK PERFORMED UNDER BLOCK 6 ACTION (IF NONE, STATE WHY):

9. OFFEROR/CONTRACTOR OCI EVALUATION AND ASSESSMENT (IF EITHER ANSWER IS YES, ATTACH A COPY OF THE STATEMENT OF WORK (SOW) OR PERFORMANCE WORK STATEMENT (PWS) AND COMPLETE BLOCK 10):

(A) DOES ACTUAL OCI EXIST? ☐ YES ☐ NO

(B) DOES POTENTIAL OCI EXIST? ☐ YES ☐ NO

10. DESCRIPTIVE SUMMARY OF ACTUAL OR POTENTIAL OCI, INCLUDING ACTIONS PLANNED TO AVOID, NEUTRALIZE, OR MITIGATE CONFLICTS OR POTENTIAL CONFLICTS:

ORGANIZATIONAL CONFLICT OF INTEREST GUIDE

APPENDIX 10—ANALYSIS FORM

UNCLASSIFIED

INSTRUCTIONS FOR COMPLETING OCI DISCLOSURE AND ANALYSIS FORM

Blocks 1 through 5: Self-explanatory.

Block 6: Fill in the contract number and the short, official program title by which the contract or subcontract requiring analysis and determination is formally known. This is work that has already been awarded, is being performed as a prime or subcontractor by your company or planned subcontractor, and requires a comparison with that work described in Blocks 1-5.

NOTE: One OCI Disclosure and Analysis Form shall be submitted for EACH NGA contract or subcontract currently being performed that poses a potential or actual OCI for the work contemplated.

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. Continue on additional pages if more space is necessary.

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. Please be as specific as possible by citing the specific Request for Proposal (RFP)/SOW or PWS paragraph where possible. Continue on additional pages if more space is necessary.

Block 9: Place an "X" inside the appropriate parenthesis to indicate your responses.

Block 10: If you answer yes either to 9(a) or to 9(b), provide a summary of the actual or potential OCI. Discuss actions contemplated to avoid, neutralize, or mitigate potential or actual OCI. Continue on additional pages if more space is necessary.

Blocks 11, 12, and 13: Provide the name of your company official with responsibility for and authority to discuss and commit the company on matters relating to OCI issues. That official should then sign and date each form(s).

Blocks 14 through 16: STOP. To be completed by NGA Contracting Officer.