D.21 Organizational Conflicts of Interest.docx
DOCX document 25 KB Posted
- Attached to
- The VA North Texas Health Care system requires community based Outpatient clinic (CBOC))
- Solicitation number
- 36C25726R0018
About this file
This is an Organizational Conflicts of Interest Certification form required as part of RFP 36C25726R0018 for the VA North Texas Health Care System's Sherman Community Based Outpatient Clinic (CBOC) services. The form serves as Appendix A to the solicitation and must be completed and submitted with the contractor's proposal.
The certification requires the contractor to declare whether key personnel identified in the solicitation have any past, present, or currently planned financial, contractual, organizational, or other interests that could constitute actual or potential organizational conflicts of interest relating to the provision of outpatient clinic services to the VA North Texas Health Care System. Contractors must select one of two options: either certify that no conflicts of interest exist among listed key personnel, or attach a detailed statement describing all relevant facts concerning any actual or potential conflicts and the mitigation measures the contractor's organizational or management systems would implement to address them. The form also requires contractors to provide equivalent conflict of interest certifications for any consultants and subcontractors identified in their proposals that will provide services under the solicitation. The certifying official must sign and date the completed form.
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D.20 Organizational Conflicts of Interest – RFP 36C25726R0018
APPENDIX A
Contractor Name Address
SOLICITATION 36C25726R0018
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 [36C25726R0018 – Sherman CBOC] 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 VA North Texas Health Care System 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 VA North Texas Health Care System 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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