ATTACHMENT 3 - Combined NDA.OCI, IHS DDTP Multiple Services Requirement.pdf

Indian Health Services Division of Diabetes Treatment and Prevention

Multiple Services Requirement

Combined Non‐Disclosure Agreement

Organizational Conflict of Interest Certification

Reference: IHS DDTP Multiple Services Requirement

1. In the course of participating either in a direct (i.e., core team member) or in an advisory role (i.e., ad hoc team member) in support of a the IHS DDTP Multiple Services Requirement review and evaluation, I may be given access to or entrusted with sensitive government information, such as data identified as Business Sensitive, Procurement Sensitive, Proprietary (e.g., 41 USC section 423, the Procurement Integrity Act restrictive legend per Federal Acquisition Regulation (FAR) 52.215‐1) or Source Selection Information (as defined in FAR 3.104‐3) that may be associated with the ongoing procurement. These sensitive data include, but are not limited to, all data, information and software, regardless of the medium, e.g. electronic or paper, and/or format in which the data exist, and includes data that are derived from, Source Selection, Business Sensitive, Procurement Sensitive and/or Proprietary Data (collectively referred to herein as "the data").

2. I agree not to discuss with, disclose, release, reproduce or otherwise provide or make available the data, or any portion thereof, to any other government or non‐government employee, person, or organization unless that other employee, person, or organization has signed a Combined NDA/OCI for this procurement and the Contracting Officer has approved at the end of this review and evaluation.

Furthermore, I agree to adhere to all safeguards established for the data and to use the data solely for the purpose of performing my role in support of the IHS DDTP Multiple Services Requirement review and evaluation.

3. I agree that these obligations not to inappropriately use, discuss, disclose, release, reproduce or otherwise provide or make available the data are binding upon me as required by applicable laws, regulations, and Department of the Interior directives.

4. I understand that any inappropriate use, disclosure, release or reproduction of the data is unauthorized and may result in criminal, civil and/or administrative penalties. I understand that nothing in this Combined NDA/OCI changes, alters or, otherwise, is intended to replace the requirements of any applicable laws, regulations and Department of the Interior directives. I freely and willingly sign this document, fully understanding its contents. I certify that I will not disclose any information concerning the evaluation, the number of offers received, the identity of the offerors, or the contents of the proposals to any party who is not authorized access to the information by law, regulation, or pursuant to the order of a court of competent jurisdiction, and then only to the extent that such information is required in connection with such person's official responsibilities.

I, hereby certify that to the best of my knowledge, neither I nor my spouse, dependent child, general partner, or any organization for which I am serving as an officer, director, trustee, general partner or employee, or any person or organization with whom I am negotiating or have an arrangement concerning prospective employment has a financial interest in this matter.

I further certify to the best of my knowledge that this matter will not affect the financial interests of any member of my household. Also, to the best of my knowledge, no member of my household; no relative with whom I have a close relationship; no one with whom my spouse, parent or dependent child has or seeks employment; and no organization with which I am seeking a business relationship nor which I now serve actively or have served within the last year are parties or represent a party to the matter.

Indian Health Services Division of Diabetes Treatment and Prevention

Multiple Services Requirement

I also acknowledge my responsibility to disclose the acquisition of any financial or personal interest as described above that would be affected by the matter, and to disclose any interest I, or anyone noted above, has in any person or organization that does become involved in, or is affected at a later date by, the conduct of this matter.

PRINTED NAME: _________________________________________________________________

POSITION/TITLE: ________________________________________________________________

SIGNATURE: _____________________________________________________________________

Privacy Act Statement

Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 and 5 CFR Part 2634, Subpart I require the reporting of this information. The primary use of the information on this form is for review by officials of the Justice Department to determine compliance with applicable federal conflict of interest laws and regulations. Additional disclosures of the information on this report may be made: (1) to a federal, state or local law enforcement agency if the Justice Department becomes aware of a violation or potential violation of law or regulations; (2) to a court or party in a court or federal administrative proceeding if the government is a party or in order to comply with a judge‐issued subpoena; (3) to a source when necessary to obtain information relevant to a conflict of interest investigation or decision; (4) to the National Archives and Records Administration or the General Services Administration in records management inspections; (5) to the Office of Management and Budget during legislative coordination on private relief legislation; and (6) in response to a request for discovery or for the appearance of a witness in a judicial or administrative proceeding, if the information is relevant to the subject matter. This confidential certification will not be disclosed to any requesting person unless authorized by law. See also the OGE/GOVT‐2 executive branch‐wide Privacy Act system of records.