OCI Analysis Disclosure Form.doc

OCI ANALYSIS/ DISCLOSURE FORM

1. RFP Number

HQ0034-12-R-0020

2. Program Title NDU Master’s Degree Program

3. Contractor Name and Address

4. Telephone Number and POC

5. Type of work to be performed under this agreement:

7. Brief Summary/ Description of work performed under Block 6 action:

8. Relationship between requirements of Block 1 action and work performed under Block 6 action (If None, State Why):

9. Offeror/Contractor OCI Evaluation and Assessment (If either answer is yes, attach a copy of the SOW and complete Block 10):

(a) Does Actual OCI exist? ( ) Yes ( ) No

(b) Does Potential OCI exist? ( ) Yes ( ) No

10. Summary of actual/potential OCI, including actions planned to avoid, neutralize, or mitigate conflict or potential conflict:

11. Typed Name of Responsible Official

12. Signature

13. Date

14. Typed Name of Contracting Officer

15. Approval Signature

16. Date

INSTRUCTIONS FOR COMPLETING OCI ANALYSIS/ DISCLOSURE FORM

Blocks 1 through 5: Self explanatory

Block 6: Fill in the number and the short, official title by which the contract or subcontract requiring analysis and determination is formally known. This is work that has already been awarded, is being performed by your company, and requires a comparison with the work described in Blocks 1 – 5. NOTE: One OCI Analysis/ Disclosure Form shall be submitted for EACH OUSD(I) Professional Services–related contract or subcontract currently being performed.

Block 7: Provide a brief, but specific, narrative summary of the SOW and work performed on the contract or subcontract listed in Block 6, including the period of performance and the value.

Block 8: Provide a brief, but specific, narrative summary of ANY relationship between the work to be performed under the action listed in Block 1 and the previous work performed under the action listed in Block 6. Please be as specific as possible by citing the specific RFP/SOW paragraph where possible.

Block 9: Place an “X” in the appropriate ( ) for your responses.

Block 10: If you answer yes to either 9(a) or to 9(b), provide a summary of the actual or potential OCI.

Blocks 11, 12, and 13: Provide the name of your company official with the responsibility for and/or authority to discuss and commit the company on matters related to OCI issues. That official should then sign and date each form.