D.4 COI.pdf
PDF 66 KB Posted
- Attached to
- G004--Residential Housing for Health Care for Homeless Veterans (Little Rock, Arkansas catchment area)
- Solicitation number
- 36C25626Q0005LR
About this file
This document contains two template forms for a VA medical center contract solicitation. The first form requires contractors to disclose potential conflicts of interest for key personnel and temporary emergency substitutions, with blank spaces to list names, titles, and whether they are prime or subcontractor employees. The second form requests detailed workforce allocation information for physicians, including average weekly hours worked, percentage of effort dedicated to VA duties, and percentage of effort for their overall practice group. Both forms appear to be part of a comprehensive solicitation package that requires bidders to provide transparent staffing and potential conflict details as part of their proposal submission.
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Other files
| File | Type | Posted |
|---|---|---|
| D.1 QASP HCHV CERS Sex Offender.pdf | ||
| 36C25626Q0005LR.docx | DOCX document | |
| D.2 WD 2015_5117 28.pdf | ||
| D.3 Contractor Certification .pdf | ||
| 36C25626Q0005LR.pdf |
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Text version
Contractor____________________ represents that the individuals listed below for Key Personnel and Temporary Emergency Substitutions of this solicitation here 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 Veterans Health Care System of the Ozarks under the solicitation/contract here in.
None of the employees listed below in this 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 Overton Brooks VA Medical Center, under the solicitation/contract here in.
Please identify also, if they are an employee of the prime or subcontractor.
NAME TITLE PRIME OR SUBCONTRACTOR
Provide the number of hours worked weekly by each of the physicians. Do not limit the response to the number of hours expended or expected to be spent at VA; provide the total number of hours worked weekly by the physicians, including time spent in research, clinical, administrative, and other duties for the Practice group.
Provide the expected percentage of total effort for each proposed physician that will be provided fulfilling the duties and responsibilities specified in the Performance Work Statement.
Additionally, provide the percentage of total effort that each proposed physician will be expected to spend fulfilling non-VA obligations. This can be expressed as a percentage of the physician’s total annual effort.
PHYSICIAN
NAME
AVERAGE
WEEKLY
HOURS
PERCENT OF
EFFORT –VA
PERCENT OF
EFFORT –
PRACTICE
GROUP
File details come from the government source that posted it. Updated .