D.5 Organizational Conflict of Interest.pdf
PDF 179 KB Posted
- Attached to
- Onsite Dermatologist Services Federal contract opportunity
- Solicitation number
- 36C25623Q1320
About this file
This document is an organizational conflict of interest disclosure form for solicitation number 36C25622Q0195 for onsite hospitalist services. The form requires the contractor to disclose any present, planned, or past financial, contractual, or organizational conflicts of interest relating to providing the services. If conflicts exist, an attached statement must describe all relevant facts. Similar disclosure statements must also be provided for any consultants or subcontractors. The contractor may provide information on how their systems or actions would avoid or mitigate any actual or potential organizational conflicts. The completed form must be signed and dated by a certifying official for the contractor.
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Text version
D.2 ATTACHMENT – 36C25622Q0195 HOSPITALIST SERVICES
Insert Contractor Name and Address Below:
SOLICITATION # 36C25622Q0195
CONFLICT OF INTEREST
[ ]Enter Contractor’s Name , represents that the proposed Physician personnel for solicitation 36C25622Q0195 for onsite hospitalist services has 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 Central Arkansas Veterans Healthcare System (CAVHCS) under the referenced solicitation.
None of the proposed 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 CAVHCS 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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