Vendor Conflict of Interest (COI) Assessment Form

COI Assessment Case No. (To be completed by Metrolinx)
Case No.	Assessed By (the “Assessor”):	Choose an item.

Pursuant to the Metrolinx Vendor Conflict of Interest Policy dated October 17, 2017 or as further amended (the “Policy”), Metrolinx and vendors have a shared responsibility and accountability for identifying and managing Conflicts of Interest (as defined in Policy).

Vendors must disclose any Conflicts of Interest, or previously implemented mitigation strategies, if any, to Metrolinx in a timely manner.

The purpose of this intake form is to document facts, circumstances, materials and information related to each COI assessment request, in order to make a determination on whether a conflict of interest exists and whether proposed mitigation measures can be implemented.

Metrolinx’s determination is based on the facts and information provided at the time of assessment. Metrolinx reserves the right to change the determination If any new information is received.

Completed Vendor Conflict of Interest Assessment Forms should be submitted to CVR@metrolinx.com along with any supporting documentation and the Requestor represents that the information submitted is factual and accurate.

The vendor will receive a Conflict of Interest assessment case number (the “Case No.”) within two business days of receipt of a completed intake form.

COI assessment requests made by a vendor on behalf of another organization, will not be accepted. The organization requesting to be assessed for the Conflict of Interest must be the firm completing and submitting this form.

Any enquiries related to your COI assessment request should be directed to CVR@metrolinx.com

Section 1 – Vendor Details (To be completed by Requestor)
Date Submitted:	Click here to enter a date.
Submitted By – Insert Vendor Legal Name (the “Requestor”):
Contact Person:	Name: Click here to enter text. Phone No: Click here to enter text. Email: Click here to enter text.

Section 2 – Conflict of Interest Details (To be completed by Requestor)
Explain in detail, the actual, perceived or potential conflict of interest issue/concern, and the parties involved: Click here to enter text. Describe the scope of services/work related to this COI request and list applicable documents in Section 4: Click here to enter text.
Is this COI request related to a procurement? Y ☐ N ☐ If yes, select which is applicable to your COI: Choose an item. If yes, what is the procurement number: Click here to enter text.
Is there any overlap or relation between the COI request and existing Contracts? Y ☐ N ☐ If yes, complete Section 4 below.
Section 3 – Reference Documents (To be completed by Requestor)
Are you carrying out work as either a prime vendor or subvendor on any contract(s) related to this COI request, whether through a contract directly with Metrolinx, or through a party such as IO or MTO (referred to as “Contracts”)? Y ☐ N ☐
If yes, please list below all such Contracts: Contract No. Contract Title & Vendor Role (Prime = (P) Subvendor = (S)) Vendor Contact Owner Contact Please attach the above-referenced Contracts.
Have you executed any ethical wall agreements for work relevant to this COI request? Y ☐ N ☐ If yes, please attach a copy of each agreement.
Is your firm currently listed on any ineligible or precluded list related to the work of this COI request? Y ☐ N ☐ If yes, please attach a copy of any ineligible or precluded lists.
Section 4 – Vendor Organizational Structure (To be completed by Requestor)
Provide the following information regarding your organization. (Information may be provided in a separate document.)
Corporate organizational reporting structure: Click here to enter text.
Number of Employees: Click here to enter text.
A listing of your company locations: Click here to enter text.
The names of other legal entities which fall under your organization’s group of companies (if applicable): Click here to enter text.

Additional Questions

COI Assessment Case No.
Case No.	Assessed By (the “Assessor”):	Choose an item.

Section 5 – Additional Questions (Additional questions and clarification requests will be noted in this section by Metrolinx, for response by the vendor)