Company Name: C.N. Associates, Inc.
Date: July 6, 2011
Subcontractor to: ORAU
Subcontractors providing personnel performing work under Oak Ridge Associated Universities (ORAU) Contract Number 200-2009-29263 with the Centers for Disease Control and Prevention, Dose Reconstruction and related activities to support National Institute for Occupational Safety and Health (NIOSH) responsibilities under the Energy Employees Occupational Illness Compensation Program Act of 2000, are required to complete all fields presented below in order to identify any and all U.S. Department of Energy (DOE) and/or Atomic Weapons Employer (AWE) sites where corporate conflicts or bias (COB) might exist. In addition, the subcontractor’s contracting officer must sign the COB agreement statement at the end of the form.
Notes:
Routine access to this completed form will be limited to ORAU Team employees with an established need to know the information and that have agreed not to disclose the contents of the completed forms to other individuals that do not have a need to know. Upon request, access to this completed form may be granted to certain NIOSH personnel, but only to individuals that have agreed not to disclose the information to other parties not having an established need to know.
Specific sites where it has been established that your company has an active COB will be included in the COB lists on the Web Disclosure Statements of the individual employees that you provide to the ORAU Team. These Web Disclosure Statements are made available to the general public on the ORAU Team’s general information Web site at www.oraucoc.org. Sites where the individual employee has identified a personal COB will also be listed on his/her Web Disclosure Statement.
Complete the form fields below using the Tab key to travel through the form. If
needed, type a continuation page in Arial 9 pt, referencing the item number.
Continuation pages?
1. Identify any current DOE or AWE site contracts that involve the management or direction of radiation protection and health physics program policies, practices, and/or procedures, or any contracts involving DOE-funded dose assessments or reconstructions for workers at that site:
Site: None
Client:
Dates:
2. Identify any previous DOE or AWE site contracts that involved the management or direction of radiation protection and health physics program policies, practices, and/or procedures, or any contracts involving DOE-funded dose assessments or reconstructions for workers at that site:
Site: None
Client:
Dates:
3. Identify any future DOE or AWE site contracts that might involve DOE sites where your company (1) is to be the prime contractor (i.e., Management and Operation [M&O]/Management and Integration [M&I]), a team member to a prime contractor, a program manager or subcontractor managing dosimetry programs, or (2) otherwise intends to be responsible for the management or direction of radiation protection and health physics program policies, practices, and/or procedures for that site; and the anticipated effective start dates for any such contracts:
Site: None
Client:
Dates:
4. Identify any DOE or AWE sites where your company is, was, or might in the future support, directly or indirectly, decision-making in a radiation dosimetry program. This includes any sites where your company is an M&O or M&I contractor, a team member subcontracted to an M&O or M&I contractor, or a program manager of such a program. For future contracts, provide the anticipated start dates:
Site: None
Client:
Dates:
5. Identify any DOE or AWE sites where your company has broad technical support contracts or task-based contracts in place whose statement of work permits the management or direction of radiation protection and health physics program policies, practices, and/or procedures, or could be modified to include this type of work.
Site: None
Client:
Dates:
6. Identify any DOE or AWE sites where your company has an active interest in bidding on work activities that would involve the management or direction of radiation protection and health physics program policies, practices, and/or procedures, or direct or indirect support to decision-making in radiation dosimetry programs.
Site: None
Client:
Dates:
C.N. Associates, Inc., as a condition of performing work on the ORAU Team Dose Reconstruction Project, hereby agrees to the following terms and restrictions:
1. We shall direct our employees that are, or might be in the future, requested to serve as:
a. Dose Reconstructor or Peer Reviewer for dose reconstruction reports,
b. Document Owner (Team Leader) of site profile documents, or
c. Lead Technical Evaluator or Peer Reviewer for draft special exposure cohort petition evaluations, to recuse themselves from the performance of these duties for any documents that pertain to any of the DOE or AWE sites that are specifically listed above.
2. In concert with ORAU, we shall ensure that such recusals are carried out.
3. We shall promptly update and resubmit this COB disclosure and agreement whenever any changes are necessary for the information on this form to be complete and accurate.
Contracting Officer: Signature on File, 7/6/11
Corporate Position: President
Print Name: Ron Cardarelli
Witness: Signature on File, 7/6/11
Print Name: Fred Levesque