Res 2009-064 - Laserfiche WebLink

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FORM D: ADMINISTRATIVE INFORMATION continued Conflict of Interest and Contract History The respondent must disclose any existing or potential conflict of interest relative to the performance of the requirements of this RFP. Examples of potential conflicts include an existing or potential business or personal relationship between the respondent, its principal, or any affiliate or subcontractor, with DSHS, the Health and Human Services Commission, or any other entity or person involved in any way in any project that is the subject of this RFP. Similarly, any existing or potential personal or business relationship between the respondent, the principals, or any affiliate or subcontractor, with any employee of DSHS, or the Health and Human Services Commission must be disclosed. Any such relationship that might be perceived, or represented as a conflict, must be disclosed. Failure to disclose any such relationship may be cause for contract termination or disqualification of the proposal. If, following a review of this information, it is determined by DSHS that a conflict of interest exists, the respondent may be disqualified from further consideration for the award of a contract. Pursuant to Texas Government Code Section 2155.004, a respondent is ineligible to receive an award under this RFP if the bid includes financial participation with the respondent by a person who received compensation from DSHS to participate in preparing the specifications or the RFP on which the bid is based. 3. Does anyone in the respondent organization have an existing or potential conflict of interest relative to the performance of the requirements of this RFP? ? YES ? NO If YES, detail any such relationship(s) that might be perceived or represented as a conflict. (Attach no more than one additional page.) 4. Will any person who received compensation from DSHS for participating in the preparation of the specifications or documentation for this RFP participate financially with respondent as a result of an award under this RFP? ? YES ? NO If YES, indicate his/her name, job title, agency employed by, separation date, and reason for separation. Has any member of respondent's executive management, project management, governing board or principal officers been employed by the State of Texas 24 months prior to the proposal due date? ? YES ? NO If YES, indicate his/her name, job title, agency employed by, separation date, and reason for separation. 6. If the respondent is a private nonprofit organization, does the executive director or other staff serve as voting members on the organizations governing board? ? YES ? NO 7. Has respondent had a contract with DSHS within the past 24 months? ? YES ? NO If YES, list the DSHS contract and attachment number(s): DSHS Contract Number(s) Page 32 RFP# EMS/LPG - 0328.1