Attachment17-OCIDocument-Revised4.xls
XLS spreadsheet 39 KB Posted
- Attached to
- MiDAESS Industry Day Briefings - 18-19 Feb 09
- Solicitation number
- HQ0006-07-R-0012
- Issued by
-
DOD Missile Defense Agency
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Attachment 17 - OCI Form
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Text version
OCI Disclosure & Analysis Form
| MiDAESS |
| OCI Disclosure & Analysis Form |
| Instructions: Use the "Tab" key and/or mouse pointer to navigate this form. Upon completing this form save using the following name format: "OCI-Company Name or Abbreviation.xls". This form must be submitted in Microsoft Excel to: MiDAESS@mda.mil. If you have difficulties using this form please contact: Ellery Williams at (256) 450-1497. Reference clause section H-08 e.(1) "Disclosing conflicts of interest" of the RFP. Follow instructions below to complete: |
| Blocks 1 and 2: Self Explanatory. |
| Blocks 3 and 4: Self Explanatory. |
| Block 5: Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist. Immediately to the right, list the contract/subcontract numbers with titles needing analysis and a Contracting Officer determination. |
| Block 6: Provide brief summaries of the work performed under the contract/subcontract(s) listed in Block 5. Include the period of performance and the total contract value. |
| Block 7: Place an "X" for Yes or No in the appropriate box. |
| Block 8: If you answered "yes" to either 8(a) or 8(b), provide a description of the OCI and proposed |
mitigation actions to avoid or neutralize the conflict.
| Block 9: Provide contact information if you want us to schedule a meeting with you. | ||||||
| NOTE: Submit one OCI Disclosure and Analysis Form EACH functional area or sub-area requiring analysis and a Government OCI determination. | ||||||
| 1. Solicitation/Contract Number: | 2. Program Title: | |||||
| HQ0006-07-R-00012 | Missile Defense Agency Engineering and Support Services (MiDAESS) | |||||
| 3. Your Company's Name and Address: | ||||||
| (a) Company Name | (b) Address | |||||
| (c) City | (d) State | (e) Zip Code | ||||
| 4. Point of Contact, Telephone Number, and Email Address: | ||||||
| (a) Name | (b) Phone | (c) Email | ||||
| 5. Areas of work that could cause a conflict for your company: Check the appropriate box(es), then to the right of the checked box, enter Contract/Subcontract Numbers and Titles of other MDA or BMDS-related work requiring analysis. | ||||||
| (a) Providing Systems Engineering and Technical Direction | ||||||
| (b) Preparing Specifications or Work Statements | ||||||
| (c) Providing Technical Evaluation or Advisory & Assistance Services | ||||||
| (d) Access to Proprietary Information of Others | ||||||
| (e) Providing products, hardware, or software to MDA or another contractor for use within MDA | ||||||
| (f) MDA Contracts/MDA Funded Contracts | ||||||
| 6. Brief Summary/Description of work performed under each contract/subcontract listed in Block 5: | ||||||
| 7. OCI Evaluation and Assessment:If your answer is "No" to both questions it is not necessary to request a meeting or return this form. | ||||||
| (a) Do you believe an Actual OCI exists? | Yes | No | ||||
| (b) Do you believe a Potential OCI exists? | Yes | No | ||||
| 8. Descriptive summary of each actual/potential OCI, including mitigation actions planned to avoid or neutralize the conflict: | ||||||
| 9. Meeting Request: | ||||||
| Do you wish to meet with MDA officials to discuss your OCI issues? | Yes | No |
Insert name Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
Provide brief summaries of the work performed under the contract/subcontract(s) listed in Block 5.
Place an "X" for Yes or No in the appropriate box.
If you answered "yes" to either 8(a) or 8(b), provide a description of the OCI and proposed mitigation actions to avoid or neutralize the conflict.
Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
Place an "X" for Yes or No in the appropriate box.
Place an "X" for Yes or No in the appropriate box.
Place an "X" for Yes or No in the appropriate box.
Place an "X" for Yes or No in the appropriate box.
Place an "X" for Yes or No in the appropriate box.
Insert phone number Insert e-mail address Self Explanatory.
Self Explanatory.
Self Explanatory.
Self Explanatory.
Self Explanatory.
Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
Check the appropriate box(es) for the types of work where you believe conflicts of interest, real or perceived, exist.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
List the contract/subcontract numbers and titles needing analysis and a Contracting Officer determination.
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