S02 D.7 Organizational Conflicts of Interest.docx
DOCX document 25 KB Posted
- Attached to
- Q523--Intraoperative Neuromonitoring (IONM) Services South Texas Veterans Health Care System
- Solicitation number
- 36C25726Q0274
About this file
This is an Organizational Conflicts of Interest Certification Statement form for RFQ 36C25726Q0274, a solicitation for Intraoperative Neuromonitoring (IONM) Services at the South Texas Veterans Health Care System under the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 17.
The certification requires the contractor to declare whether key personnel and temporary emergency substitutions identified in the solicitation have any past, present, or currently planned financial, contractual, organizational, or other interests that could constitute actual or potential conflicts of interest relating to the neuromonitoring services to be provided. Contractors must select one of two options: certify that no conflicts of interest exist for listed personnel, or submit an attached statement detailing all relevant facts concerning any conflicts. If conflicts are identified, the offeror may also provide information demonstrating how its organizational and management systems would mitigate or avoid such conflicts. The form requires the certifying official to provide their name, title, signature, and date. Additionally, contractors must provide equivalent conflict of interest statements for any identified consultants and subcontractors that will perform services under the solicitation.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25726Q0274 0001.docx | DOCX document | |
| D.8 PAST PERFORMANCE SURVEY 36C25726Q0274.docx | DOCX document | |
| S02 D.2 Intraoperative Neuromonitoring Communication Log _ Sample.docx | DOCX document | |
| S02 D.6 Contractor Certification - Immigration and Nationality Act.docx | DOCX document | |
| S02 D.5 Contractor Rules of Behavior.docx | DOCX document | |
| S02 D.4 VHA Directive 1088 Communicating Test Results to Providers and Patients.pdf | ||
| S02 D.1 QASP Neuromonitoring.pdf | ||
| 36C25726Q0274_1.docx | DOCX document |
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Text version
D.7 Organizational Conflicts of Interest – RFQ 36C25726Q0274
APPENDIX A
SOLICITATION 36C25726Q0274
CONTRACTOR CONFLICT OF INTEREST CERTIFICATION STATEMENT
[ ] Contractor represents that the individuals listed in the Key Personnel and Temporary Emergency Substitutions section of the solicitation [36C25726Q0274 – Neuromonitoring 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 VA Medical Center 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 Medical Center 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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