D.5 VA Contractor Conflict of interest Certification Statement.docx
DOCX document 13 KB Posted
- Solicitation number
- 36C24623Q0900_2
About this file
This document contains a contractor conflict of interest certification statement and information about a related federal contract opportunity for intraoperative neurophysiologic monitoring services. The contractor conflict of interest certification statement is a template requiring the contractor to certify that the individuals listed in the key personnel section of solicitation 36C24623Q0900 have no present or planned conflicts of interest relating to the services to be provided to the Durham Veterans Affairs Medical Center. The contractor must also disclose any past conflicts of interest.
The related federal contract opportunity is solicitation 36C24623Q0900_2 issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 6 for intraoperative neurophysiologic monitoring services. The solicitation seeks these monitoring services to be provided to the Durham Veterans Affairs Medical Center.
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Other files
| File | Type | Posted |
|---|---|---|
| S06_36C24623Q0900 0001 Q and A Amendment.pdf | ||
| S02_36C24623Q0900 (IONM).pdf | ||
| D.1 Past Performance Questionnaire.docx | DOCX document | |
| D.3 Quality Assurance Surveillance Plan.docx | DOCX document | |
| D.2 Contractor Certification.docx | DOCX document | |
| CONTRACT DISCREPANCY REPORT.docx | DOCX document | |
| D.4 VA National Rules of Behavior.docx | DOCX document |
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Text version
D.5 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 36C24623Q0900 for 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 Durham 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 Durham Veterans Affairs Medical Center (Durham 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 Quote containing the same information for any consultants and subcontractors identified in its Quote 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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