D.5 CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT.docx
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- Solicitation number
- 36C24626Q0496
About this file
This is a Contractor Conflict of Interest Certification Statement form required for solicitation 36C24626Q0496 for Off-Site Tele-Radiology Services at the Asheville VA Medical Center. The form requires contractors to certify that key personnel identified in the solicitation have no present, planned, or past financial, contractual, organizational, or actual conflicts of interest related to the services being provided to VA Medical Centers. Contractors must select one of two options: either certify that no conflicts of interest exist, or provide an attached statement describing all relevant facts concerning any past, present, or currently planned conflicts of interest, along with mitigation measures if applicable.
The form requires contractors to provide identical conflict of interest certifications for any consultants and subcontractors identified in their proposal that will provide services under the solicitation. The certifying official must sign and date the form, including their name and title. This is a template document that must be completed and submitted as part of the proposal package for the tele-radiology services contract, which will be awarded to a Board Certified or Board Eligible Radiology Physician Services provider serving beneficiaries of the Department of Veterans Affairs at the Asheville VAMC location.
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Text version
36C24626Q0496
D.5 CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ______________________________ represents that the individuals listed in the Key Personnel section of the solicitation 36C24626Q0496 for Offsite Tele-Radiology 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 VA Medical Centers 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 Medical Centers 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 proposal 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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