S02 D.5 Organizational Conflicts of Interest - Teleradiology.docx
DOCX document 25 KB Posted
- Solicitation number
- 36C25726Q0522
About this file
This is a Contractor Conflict of Interest Certification Statement template for RFQ 36C25726Q0522, a teleradiology services solicitation for the Central Texas Veterans Healthcare System under the Department of Veterans Affairs Veterans Health Administration.
The certification form requires contractors to declare whether key personnel identified in the solicitation have any present, past, or currently planned financial, contractual, organizational, or other conflicts of interest relating to the provision of teleradiology physician services. Contractors must select one of two options: certify that no conflicts exist, or attach a detailed statement describing all relevant facts concerning any actual or potential organizational conflicts of interest. If conflicts are identified, contractors may provide information demonstrating how their organizational and management systems would mitigate or avoid such conflicts. The form requires signature and certification by an authorized official and applies to all consultants and subcontractors who will provide services under the solicitation.
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| S02 D.4 Contractor Cert - Immigration_Nationality Act - Teleradiology.docx | DOCX document | |
| S02 D.1 - Teleradiology Quality Assurance Surveillance Plan (2).pdf | ||
| S02 SOLICITATION - 36C25726Q0522_1.docx | DOCX document | |
| S02 D.3 Contractor Rules of Behavior - Teleradiology.docx | DOCX document | |
| S02 D.2 Past Performance Questionnaire - Teleradiology Physician Services.docx | DOCX document |
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Text version
D.20 Organizational Conflicts of Interest – RFQ 36C25726Q0522 – Teleradiology CTX
APPENDIX A
Contractor Name______________________ Address _____________________________
SOLICITATION 36C25726Q0522
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] _____________________________ (contractor name) represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [36C25726Q0522– Teleradiology Physician Services] 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 Central Texas Veterans Health Care System 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 Central Texas Veterans Health Care System 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 quoter shall also provide statements with its quote containing the same information for any consultants and subcontractors identified in its solicitation and which will provide services under the solicitation. The quoter 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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