Attachment N COI Acknowledgement Form.docx
DOCX document 41 KB Posted
- Solicitation number
- SFGOV-0000011940
- Issued by
- California
About this file
This is a Conflict of Interest and Acknowledgement Form prepared by the City and County of San Francisco's Department of Public Health for the Institutional Master Plan (IMP) Consulting Services contract opportunity (SFGOV-0000011940). The form requires proposers to disclose any current or past economic, financial, or other relevant relationships with specified healthcare facilities that may submit IMPs for City review, including Chinese Hospital, Sutter Health California Pacific Medical Center (with locations at Van Ness, Mission, Bernal, and Davies), and Kaiser Permanente San Francisco. Proposers must acknowledge their ability to maintain fair and impartial evaluation of IMPs and certify the absence of conflicts of interest that would compromise their objectivity. The form requires disclosure of any relationships with specified facilities, including dates and the nature of the relationship, with the Procurement Officer and City Attorney responsible for reviewing submissions to determine whether actual conflicts exist.
Proposers are strongly encouraged to review the conflict of interest definition provided, which encompasses any action affecting the proposer's financial interest or that of family members or domestic partners, or any action that could appear to affect impartiality. Authorized representatives must provide their printed name, title, date, and signature on the acknowledgement section. The form serves as a critical compliance document for the procurement process, with the pre-proposal conference scheduled for September 18, 2026, proposal deadline on October 13, 2026, estimated award announcement in November 2026, and contract start date of June 1, 2027.
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Attachment N Conflict of Interest and Acknowledgement Form
SFGOV-0000011940
Institutional Master Plan Consulting Services
The undersigned does hereby acknowledge and agree to the following:
Conflict of Interest: Actual or Perceived Proposers are strongly encouraged to review the list of facilities included in this solicitation that may submit an Institutional Master Plan (IMP) for review. If you currently have, or previously had, an economic relationship with any of the listed facilities below, we recommend that you consult with your attorney to ensure there is no conflict of interest that would preclude you from submitting a proposal.
| Network/Chain |
| Hospital |
Chinese Hospital
| Sutter Health |
| California Pacific Medical Center (CPMC) Van Ness, Mission Bernal, Davies |
| Kaiser Permanente |
| Kaiser Permanente San Francisco |
A conflict of interest for purposes of this document is defined as any action by a proposer in the IMP evaluation process which would affect, or could appear to affect, the proposer’s financial interest (including any family members or domestic partner of the proposer), or would cause the proposer’s impartiality in the IMP evaluation process to be questioned. Proposers should be sufficiently independent of the entities submitting IMPs to the City and must be able to render an objective and unbiased evaluation.
If you have concerns that you may have a conflict, please specify the possible conflict below. The Procurement Officer and/or City Attorney will review the information and determine whether a conflict exists.
Conflict of Interest Disclosure Please describe any current or past economic, financial, or other relevant relationship you have had with any of the facilities listed above that may submit an IMP for review. Include dates and the nature of the relationship.
Disclosure (if applicable). If you have no potential conflicts to disclose, write “None”:
Click or tap here to enter text.
Acknowledgement I acknowledge that I can be fair and impartial in the IMP evaluation process and that I do not have a conflict of interest as stated above.
Authorized Representative’s Printed Name: Click or tap here to enter text.
Authorized Representative’s Title: Click or tap here to enter text.
Date: Click or tap here to enter text.
Authorized Representative’s Signature:
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