Attachment 5 - Org Conflict of Interest.docx

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Q522--LOCUM - Radiological Physicists - 626 POP: 10/1/2022-9/30/2023 +4 options years contract end date 9/30/ 2027
Solicitation number
36C24922R0002
Issued by

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This combined synopsis/solicitation from the Department of Veterans Affairs seeks proposals for radiological physicist inspection services. The Tennessee Valley Veteran Healthcare requires a contractor to provide non-personal services for its radiology department, with a base period of performance from October 2022 to September 2023 plus four one-year option periods. Offerors should submit technical and price proposals by July 1, 2021 detailing their experience, licenses, certifications, and prices for the base year and each option period. The award will be made to the offeror representing the best value based on technical and price factors. The solicitation is set aside for service-disabled veteran-owned small businesses.

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Other files

File Type Posted
36C24922R0002 0002.docx DOCX document
Attachment 1 Physics SOW.docx DOCX document
36C24922R0002 0001.docx DOCX document
Attachment 2 Price Schedule.doc DOC document
Attachment 6 - Past Performance Questionnaire.docx DOCX document
Attachment 1 Physics PWS.docx DOCX document
Attachment 3 - Contractor Certification of Immigration.docx DOCX document
36C24922R0002.docx DOCX document
Attachment 7 equiptment list.docx DOCX document
Attachment 4 - Contractor Rules of Behavior.docx DOCX document

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ATTACHMENT 5 – 36C24922R0002

[CONTRACTOR NAME]

[ADDRESS]

SOLICITATION #36C249-22-R-0002

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 Tennessee Valley Healthcare (TVH) 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 Tennessee Valley Healthcare (TVH) 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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