Attachment_3_-_OCI_Analysis_Disclosure_Form.pdf

Attachment 3

RFP HQ0147-15-R-0004

OCI Analysis/Disclosure Form

1. Contract Number 2. Program Title

3. Contractor Name and Address 4. Telephone Number and POC

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

(a) Providing Systems Engineering and Technical Direction ( )

(b) Preparing Specifications or Work Statements ( )

(c) Providing Technical Evaluation or Advisory & Assistance Services (x)

Other MDA or BMD-related work requiring analysis and determination:

6. Contract Number and Program Title

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

Attachment 3, RFP HQ0147-15-R-0004

INSTRUCTIONS FOR COMPLETING OCI ANALYSIS/DISCLOSURE FORM

Blocks 3 and 4: 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 that work described in Blocks 1-5.

NOTE: One OCI Analysis/Disclosure Form shall be submitted for EACH BMD or BMD-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 either to 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 responsibility for and/or authority to discuss and commit the company on matters relating to OCI issues. That official should then sign and date each form.