D.4 Conflicts of Interest Certification Statement Tazewell CBOC.docx

D.4 Conflicts of Interest 36C24621R0068

CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT

All healthcare contracts require response to the following provision as prescribed in VAAR 809.507-1(b). Please use the form in APPENDIX A to provide response.

(a) It is in the best interest of the Government to avoid situations which might create an organizational conflict of interest or where the offeror’s performance of work under the contract may provide the contractor with an unfair competitive advantage. The term “organizational conflict of interest” means that because of other activities or relationships with other persons, a person is unable to render impartial assistance or advice to the Government, or the person’s objectivity in performing the contract work is or might be otherwise impaired, or the person has an unfair competitive advantage.

(b) The offeror shall provide a statement with its offer which describes, 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.

(c) Based on this information and any other information solicited or obtained by the contracting officer, the contracting officer may determine that an organizational conflict of interest exists which would warrant disqualifying the contractor for award of the contract unless the organizational conflict of interest can be mitigated to the contracting officer's satisfaction by negotiating terms and conditions of the contract to that effect. If the conflict of interest cannot be mitigated and if the contracting officer finds that it is in the best interest of the United States to award the contract, the contracting officer shall request a waiver in accordance with FAR 9.503 and 48 CFR 809.503.

(d) Nondisclosure or misrepresentation of actual or potential organizational conflicts of interest at the time of the offer, or arising as a result of a modification to the contract, may result in the termination of the contract at no expense to the Government.

APPENDIX A

CONTRACTOR NAME: ________________________________________________________

ADDRESS: ___________________________________________________________________

SOLICITATION NUMBER: 36C24621R0068

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 36C24621R0068 for Community Based Outpatient Clinic services 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 Salem Veterans Affairs Medical Center (Salem VAMC) 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 Salem Veterans Affairs Medical Center (Salem VAMC) 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