S-248000-00006188 EXHIBIT C -- Evaluation_Conflict of Interest Worksheet.pdf

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OREGON MILITARY DEPARTMENT

REQUEST FOR PROPOSAL EVALUATION WORKSHEET

Evaluator: __________________________________________________

Proposed by: __________________________________________________

Solicitation Number: S-24800-00006188 Medical Services For Firefighters @

Kingsley Field Fire Department (KFFD)

EXHIBIT C: S-24800-00006188

Offer Evaluation and Award

OAR 137-047-0600

(1) Contracting Agency Evaluation: The Contracting Agency shall evaluate Offers only as set forth in the Solicitation

Document, pursuant to ORS 279B.055(6)(a) and 279B.060(6)(b), and in accordance with applicable law. The Contracting Agency shall not evaluate Offers using any other requirement of criterion.

Evaluation Committee Member:

Proceed with Phase 2 of the evaluation if all answers to Phase 1 minimum requirements are all checked as PASS. Proposer has to meet the minimum standards in their offer before they can be considered for further evaluation. Please ensure you complete your evaluation independently and do not discuss your findings until the committee reconvenes to complete the final tabulation of all offers that undergo the evaluation process.

Detach and complete the “Certificate of Conflict of Interest” on the last page before starting your evaluations.

Phase 1: Evaluation of Minimum Requirements (PASS or FAIL)

Minimum Requirements (Responsive Offer):

A. Description of the proposing firm and the following information:

Company Name Address City, State, ZIP Contact Name Title Phone Number Fax Number E-Mail Address Federal Business Number (FID) Are You A Resident Bidder?

Corporate Affiliation (if any)

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Length of Time in Business

( ) Pass ( ) Fail – Missing: Reviewed By Initials _____ B. Your qualifications to perform the work required to complete this project. This should include a resume and a description of your experience with projects of this sort. Please describe each assignment that qualifies you to undertake the requested services. Section VIII, Evaluation, lists the criteria for the selection of a successful contractor. Please prepare your response so that it addresses each of the criteria.

C. Three (3) current business references and three (3) current personal references.

D. The following information:

1. Description of the proposing firm (include length of time in business and corporate affiliation, if any).

2. Statement indicating the proposer is a legal entity (independent contractor or corporation).

3. Statement identifying individual(s) who prepared proposal.

4. Statement that no attempt has been made or will be made by the proposer to induce any other person or firm to submit or not submit a proposal.

5. Statement of Affirmative Action that proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, sex, disability, or national origin.

6. Statement that any submitted response and costs shall remain valid for sixty (60) days after the proposal due date or until a contract is approved, whichever comes first.

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7. Statement that your business does not have an “Active Exclusion” in *SAM:

OFFEROR MUST BE CLEARED (“NO RECORDS FOUND FOR ACTIVE

EXCLUSION IN CURRENT SEARCH”) THROUGH THE EXCLUDED

PARTIES LIST SYSTEM (EPLS) TO BE ALLOWED TO RECEIVE A

FEDERALLY FUNDED CONTRACT. SEE EXHIBIT B FOR ADDITIONAL

INFORMATION.

THIS CHECK WILL BE PERFORMED BY OMD BEFORE THE OFFEROR’S

BID PACKAGE IS SUBMITTED FOR EVALUATION, TO THE

EVALUATION COMMITTEE.

NOTE: YOU DO NOT HAVE TO BE REGISTERED IN SAM, ONLY THAT

YOU DO NOT HAVE AN ACTIVE EXCLUSION.

LINK TO SAM WEBSITE: https://www.sam.gov/portal/public/SAM/

8. SAMPLE CONTRACT: Prospective contractors who submit proposals to this request shall certify that they or their firm meets or can meet all applicable requirements of these provisions in the contract example provided as EXHIBIT A of this RFP.

Insurance requirements are considered a negotiable part of this RFP.

9. Resumes of specific personnel assigned to the project. Personnel identified in the proposal and resulting contract cannot be changed by the contractor without written approval by the Agency.

10. COST: The prospective contractor will provide a (one) total cost for services:

1. Total Cost: $ _____.00 (Pg. 7 of RFP: G.: A+B+C = Total Cost $)

The formula for computing points for cost will be based upon using the following formula:

Formula: “L” Divided by “X” Times “A” Equals “B” (L/X x A = B)

Note: Contractor shall include reimbursable/travel costs, if any, as part of the contract price and is not to be included as a separate cost breakdown.

L = Lowest Price Proposal X = Price Proposal Being Compared

A = Total Possible Points B = Awarded Score https://www.sam.gov/portal/public/SAM/

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Phase 2: Evaluation of Experience

Proposals not eliminated from consideration by Phase 1 will be considered for further evaluation in Phase 2. The purpose of this phase is to determine which proposal has the highest level of experience in providing the services required and evaluate the cost. The Agency reserves the right to reject all proposals.

1. Experience in providing physicals and other medical services to fire protection personnel. 50 points

2. Experience in providing written medical evaluation reports as a result of testing 40 points

3. Total cost of the proposed contract 10 points

TOTAL POSSIBLE POINTS:100 points

Evaluator’s Justification & Explanatory Remarks

Evaluation Topics 1 - 3:

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Evaluator’s Signature/Date

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Evaluation Committee Member’s Certificate of Conflict of Interest

ORPIN RFP SOLICITATION # OMD-1802-20

I hereby certify by attestation of my signature below that:

• I do not have an “actual conflict of interest” with any proposer responding to this RFP. A conflict of interest may include any family members presently associated with a proposer, or any financial relationships with a proposer (does not include past employment);

• I have read and rated the proposals independently, and without interference or pressure from anyone;

• I have not had conversation or other contact with any of the proposers concerning this RFP since it was issued in ORPIN; and

• If applicable, I have declared a “potential conflict of interest” below.

ORS 244.020 Definitions:

(1) “Actual conflict of interest” means any action or any decision or recommendation by a person acting in a capacity as a public official, the effect of which would be to the private pecuniary benefit or detriment of the person or the person’s relative or any business with which the person or a relative of the person is associated unless the pecuniary benefit or detriment arises out of circumstances described in subsection (12) of this section.

(12) “Potential conflict of interest” means any action or any decision or recommendation by a person acting in a capacity as a public official, the effect of which could be to the private pecuniary benefit or detriment of the person or the person’s relative, or a business with which the person or the person’s relative is associated, unless the pecuniary benefit or detriment arises out of the following:

(a) An interest or membership in a particular business, industry, occupation or other class required by law as a prerequisite to the holding by the person of the office or position.

(b) Any action in the person’s official capacity which would affect to the same degree a class consisting of all inhabitants of the state, or a smaller class consisting of an industry, occupation or other group including one of which or in which the person, or the person’s relative or business with which the person or the person’s relative is associated, is a member or is engaged.

(c) Membership in or membership on the board of directors of a nonprofit corporation that is tax-exempt under section 501(c) of the Internal Revenue Code.

Business Dictionary Definition:

A situation that has the potential to undermine the impartiality of a person because of the possibility of a clash between the person's self-interest and professional interest or public interest.

Member Signature/Date

Title

If Applicable, Potential Conflict of Interest Declared: ( ) Yes* ( ) N/A

*If Yes, Please Explain: ___________________________________________________

Witness (print name) Witness (please sign/date) http://www.investorwords.com/10666/potential.html http://www.businessdictionary.com/definition/person.html http://www.investorwords.com/14646/person.html http://www.businessdictionary.com/definition/self-interest.html http://www.investorguide.com/definition/professional.html http://www.investorguide.com/definition/interest.html http://www.businessdictionary.com/definition/public-interest.html