D.6 - Organizational Conflict of Interest.pdf
PDF 141 KB Posted
- Solicitation number
- 36C26323R0032
About this file
This document contains an organizational conflict of interest certification statement template for a contractor providing Medical Officer of the Day services to the St. Cloud VA Health Care System under solicitation number 36C26323R0032. The template requires the contractor to certify that its key personnel listed in the solicitation have no present, planned, or past financial, contractual, organizational, or other conflicts of interest relating to the services. Alternatively, the contractor may provide an attached statement describing any such relevant conflicts of interest and how its system would avoid or mitigate potential organizational conflicts. It also specifies that consultants and subcontractors must provide the same conflict of interest disclosures.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C26323R0032_3.docx | DOCX document | |
| D.2 - Background Investigation Procedure and Documents-Updated.pdf | ||
| 36C26323R0032_2.docx | DOCX document | |
| D.3 - Quality Assurance Surveillance Plan (QASP).xls | XLS spreadsheet | |
| D.1 - VA Rules of Behavior.pdf | ||
| 36C26323R0032_1.docx | DOCX document | |
| D.2 - Background Investigation Procedure and Documents.pdf | ||
| D.4 - Immigration and Nationality Act Requirement.pdf | ||
| S02 - 36C26323R0032.pdf | ||
| D.5 - VA Handbook 6500.6.pdf |
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Text version
D.6 – Attachment 6 – Organizational Conflicts of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C26323R0032, Medical Officer of the Day (MOD) Services, St. Cloud VAHCS
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] _____________________(Contractor Name) represents that the individuals listed in the Key Personnel section of the solicitation 36C26323R0032, Medical Officer of the Day (MOD) 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 St. Cloud VA Health Care System 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 St. Cloud VA Health Care System 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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