S02 - Attachment D.3 - Organizational Conflict of Interest.docx
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- Solicitation number
- 36C24826Q1057
About this file
This is an Organizational Conflict of Interest (OCI) disclosure and attestation document required as part of the proposal submission for 3D Image Reconstruction and Case Planning Services. The document serves as Attachment D.3 to the solicitation and requires offerors to identify, disclose, and mitigate any potential conflicts of interest that could compromise their ability to perform objectively or provide impartial advice to the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 8 (VA VISN 8).
The attachment functions as a template for contractors to declare whether they have any organizational conflicts of interest related to the contract opportunity (Solicitation Number 36C24826Q1057), which involves providing off-site 3D image reconstruction and case planning services for endovascular procedures at the Malcolm Randall VA Medical Center. Offerors must attest to the absence of conflicts or provide detailed mitigation strategies if conflicts exist. This compliance document is essential to ensure contractor independence and objectivity in delivering digital CT scan image acquisition, assessment, multiplanar reformatting, and 3D reconstruction tools for case planning purposes.
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Attachment D.3 – Organizational Conflict of Interest RFQ #36C24826Q1057 3D Imaging and Case Planning Services Malcom Randall VAMC, NF/SG VA Healthcare System Organizational Conflict of Interest
[CONTRACTOR NAME]
[ADDRESS]
SOLICITATION # 36C24826Q1057
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] ____[CONTRACTOR NAME]________________ represents that no individuals involved with the solicitation [____Solicitation # and Service Type___] in have no present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the ___[NAME OF VAMC] _________ Veterans Administration under the referenced solicitation.
None of the employees listed in the solicitation have a past interest (financial, contractual, organizational, or otherwise) or actual or organizational conflicts of interest relating to the services to be provided to the___NAME OF VAMC _________ Veterans Administration under the referenced solicitation.
OR
[ ] Statement attached describing, in a concise manner, all relevant facts concerning any past, present, or currently planned interest (financial, contractual, organizational, or otherwise) or actual or potential organizational conflicts of interest relating to the services to be provided under this solicitation. The offeror shall also provide statements with its offer containing the same information for any consultants and subcontractors identified in its proposal and which will provide services under the solicitation. The offeror may also provide relevant facts that show how its organizational and/or management system or other actions would avoid or mitigate any actual or potential organizational conflicts of interest.
NAME OF CERTIFYING OFFICIAL
TITLE
SIGNATURE DATE
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