S02 D.7 Organizational Conflicts of Interest.docx
DOCX document 25 KB Posted
- Solicitation number
- 36C25726Q0159
About this file
This is an Organizational Conflicts of Interest (OCI) Certification Statement template for RFQ 36C25726Q0159, a federal solicitation for Locum Gastroenterology (GI) Physician Services issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17 (VISN 17) to support the South Texas Veterans Health Care System.
The document requires contractors to certify either that their key personnel and any temporary emergency substitutions have no present, past, or currently planned financial, contractual, organizational, or other conflicts of interest related to the services being provided, or to attach a detailed statement describing all relevant facts concerning any actual or potential organizational conflicts of interest. Contractors must also provide conflict of interest certifications and statements for any consultants and subcontractors identified in their quote that will perform services under the solicitation. The form permits contractors to include information demonstrating how their organizational and management systems or other actions would mitigate any identified conflicts. The certification must be signed by an authorized certifying official with their printed name, title, signature, and date provided.
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Text version
D.20 Organizational Conflicts of Interest – RFQ 36C25726Q0159
APPENDIX A
Contractor Name Address
SOLICITATION 36C25726Q0159
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 [36C25726Q0159 – Locum Gastroenterology (GI) 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 South 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 South 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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