T3054 Attachment 3 NJDOT SSO Potential Conflict of Interest COI Disclosure~1.pdf
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- Solicitation number
- 26DPP01268
- Issued by
- New Jersey
About this file
This is a Potential Conflict of Interest (COI) Disclosure form for the New Jersey Department of Transportation (NJDOT) State Safety Oversight (SSO) program related to the T3054 Light Rail/Fixed Guide State Safety Oversight Support Services contract opportunity. The form requires employees and contractors involved in the T3054 SSO program to disclose potential conflicts of interest based on current employment, financial investment, or close familial relationships with specified entities. The disclosure addresses potential conflicts with Newark Light Rail, Kinkisharyo, AECOM, 21st Century Rail Corp., Hudson Bergen Light Rail, New Jersey Transit, River LINE, Bombardier, Port Authority Transit Corp., and Delaware River Port Authority, with yes or no response options for each entity requiring detailed explanations if conflicts exist.
The form captures employee information including last name, first name, middle initial, employment type, contractor/T3054 designation, email, title, and employment duties. Each disclosure requires certification with a signature and date. The document includes internal SSO use sections for the SSO reviewer, review date, SSO project manager date, resolution plan approval or disapproval status, SSO start date, and SSO manager assignment. The form was last updated on March 28, 2018, and serves as a mandatory disclosure mechanism to ensure personnel involved in the state safety oversight support services maintain independence and transparency regarding potential conflicts with transit and rail entities and their suppliers.
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Text version
Employee Last Name First Name MI Employment Type Contractor/T‐3054
NJDOT SSO POTENTIAL CONFLICT OF INTEREST (COI) DISCLOSURE
(If "yes", please describe below.)
(If "yes", please describe below.)
(If "yes", please describe below.)
(If "yes", please describe below.)
(If "yes", please describe below.)
Do you have a Potential COI with Newark Light Rail? (If "yes", please describe below.)
Do you have a Potential COI with Kinkisharyo?
Do you have a Potential COI with AECOM?
Do you have a Potential COI with 21st Century Rail Corp.?
Do you have a Potential COI with Hudson‐Bergen Light Rail?
Do you have a Potential COI with New Jersey Transit?
You are required to disclose whether or not you have a potential conflict of interest (COI) based on current employment, financial investment, or close familial relationship with an entity shown below or any vendor supplying services to such entity.
Title Employment Duties
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
NJDOT SSO: COI Disclosure ‐ Last updated: 3/28/2018
ATTACHMENT #3
Do you have a Potential COI with River LINE?
(If "yes", please describe below.)
Do you have a Potential COI with Bombardier (If "yes", please describe below.)
Do you have a Potential COI with Port Authority Transit Corp? (If "yes", please describe below.)
Do you have a Potential COI with Delaware River Port Authority? (If "yes", please describe below.)
Disclosure Certification (Sign Date)
YESNO
YESNO
YESNO
YESNO
ATTACHMENT #2
SSO Internal Notes
SSO Reviewer
SSO Review Date
SSO PM Date
SSO Resolution Plan
Approved
Disapproved
SSO Start DateSSO Manager
FOR INTERNAL SSO USE:
ATTACHMENT #4
File details come from the government source that posted it. Updated .