DEP.RFR.BWSC.ERIRA.2017.14.Example.Conflict.of.Interest.Form.6.27.17.docx

MassDEP BWSC Contractor Conflict of Interest (COI) Screening Questionnaire and Certification (rev. 04/26/12) Contractor and Site Information

Name(s) of Parent Firm and/or Affiliates, if applicable:

Organizational Conflict of Interest Questionnaire (use list of parties at end of this form)

Questions (Note: Use of the term "Contractor" for this form includes the contractor's parent firm and/or affiliates)

To select Yes or No check boxes in MS Word, double-click on box, click on "Default value", click on Unchecked or Checked as appropriate, click on "OK".

(Check appropriate box) If answer is "Yes", go to questions on Page 2.

All firms must respond to this question by checking one of the boxes to the right.

(Check one response) In the opinion of the firm,

Personal Conflict of Interest Questionnaire

All firms must respond to this question by checking one of the boxes to the right.

(Check one response) In the opinion of the firm,

Certification of Responses to Questionnaire

I hereby certify that, to the best of my knowledge and recollection, that the responses provided in this questionnaire are true and accurate, and that I am authorized by the firm to certify and attest to these responses. I also acknowledge that MassDEP has the final decision on whether or not there is a real, potential or appearance of a conflict of interest, and as a result of that decision, MassDEP may request the firm to submit a plan to mitigate a potential conflict of interest, or may exclude the firm from work at the site or on the task.

Signature: __________________________________

Printed Name: ________________________________

Title: __________________________________

Date: ______________

Contractor Conflict of Interest Screening Form - Explanation (Page 2 to be completed if any of the responses in the questions on Page 1 are "Yes")

Site Name/ RTN No., if applicable:

for column (3) where response(s) on Page 1 was "Yes" In the space below, provide the information requested in Column (2).

(Add additional space by extending the height of the rows)

Organizational Conflict of Interest

1. Name(s) of the RP/PRP/OPs.

2. Dates when the work was performed.

3. Who performed the work, the contractor, parent or affiliated firm?

4. Where the work was performed (town or city & state)?

5. Type of work?

6. Dollar amount of work and total firm revenue in the year(s) the work was performed.

7. Whether any contractor staff who performed RP/PRP/OP work would work on the MassDEP contract.

Personal Conflict of Interest

List of Responsible Parties (RP), Potentially Responsible Parties (RP), and Other Parties (OP), including owners, for this Site for which COI Screening is to be applied.

Note: Parties listed below are not necessarily considered PRP’s, but are involved or have been involved with the site. Relationships with any of these parties does not mean that a firm will be in a conflict of interest. MassDEP will review the relationship and make a determination.

MassDEP COI Screening Form Page 1