Attachment 2 - Contractor Organizational Conflict of Interest.pdf
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- Attached to
- Q201--MSO-2020-CMP-0028 Capitated CBOC Maury County & McMinnville Base plus 6 option periods
- Solicitation number
- 36C24920R0010
About this file
This document contains an organizational conflict of interest certification statement template and details of a solicitation for community-based outpatient clinic services. The Tennessee Valley Healthcare System is seeking proposals to operate community-based outpatient clinics in McMinnville, Tennessee and Maury County, Tennessee to provide primary care services to local Veterans. Indefinite-delivery, indefinite-quantity contracts will be awarded to offerors that can successfully propose to establish and operate a clinic at the desired locations. The solicitation number is 36C24920R0010 and is anticipated for release on or around May 28, 2020. It will be posted on SAM.gov. Offerors must be registered in the VA VetBiz and SAM databases. The NAICS code is 621498 and the size standard is $22 million. Proposals will be evaluated based on responsiveness, conformance with requirements, and overall advantage to the government.
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Attachment 2 – Contractor Organizational Conflict of Interest
APPENDIX A
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION #
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.
OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.
NAME OF CERTIFYING OFFICIAL
TITLE
SIGNATURE DATE
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