3-Certification Statement.pdf
PDF 60 KB Posted
- Solicitation number
- NNMC0928OBICUAMB
About this file
This solicitation notice requests proposals for a non-personal service contract to provide registered nurse services at Northern Navajo Medical Center for the Department of Health and Human Services Indian Health Service. Services include RN positions in ambulatory care, ICU, and OB/GYN and shall be performed in accordance with the attached performance work statement. The base period of performance is from date of award to six months, with an option to extend an additional six months. Offerors must provide qualifications, past performance, availability, insurance, and pricing for candidates. Proposals are due by the dates specified, and evaluation will consider past performance, qualifications and price to determine best value. Candidates must be U.S. citizens and will be interviewed to verify qualifications and understanding of requirements.
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| File | Type | Posted |
|---|---|---|
| 2-Pricing Schedule.xlsx | XLSX spreadsheet | |
| 1-Clause OM.pdf |
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are prescribed in 18 U.S.C. 1001.
Print Name of Nurse Candidate
1. I currently [ ] meet [ ] do not meet the experience required by PWS #08-01, paragraph 6.1 - Experience.
If the experience requirement is met, attach a summary detailing employment history and job duties for the last 36 months.
2. License to practice [ ] has [ ] has not been restricted, terminated, suspended, or revoked.
If your license has been restricted, terminated, suspended, or revoked, provide a copy of the State Board of Nursing document pertaining to each occurrence.
3. I currently hold the following active, unrestricted nurse license as required by PWS #08‐01, paragraph 6.2 ‐ License/Registration (list all license):
4. I currently hold the following inactive nurse license (list all license):
5. I currently hold the following certifications as identified by the PWS #08-01, paragraph 6.3 - Certifications
Certification Expiration Certification Expiration Certification Expiration
BLS NRP
TNCC
CNOR PALS
ACLS
6. I meet the requirements of the PWS #08‐01, paragraph 6.4.1 ‐ Medical Evaluation.
My most recent medical evaluation was completed on:
7. I meet the requirements of the PWS #08‐01, paragraph 6.4.2 ‐ Immunization.
The dates of my immunizations are as follows:
a. Immunity to Rubella, Mumps, Measles MMR#1 MMR#2
b. Immunity to Hepatitis B HEP B#1 HEP B#2
HEP B#3 declination
c. History of chicken pox (varicella) disease or positive titer positive titer disease
d. Tetanus Diphtheria (Td) within the last 5 years Td
e. Documentation of receiving a TB Mantoux skin test PPD chest x-ray within the past 12 months or chest x-ray
8. I currently [ ] meet [ ] do not meet the language requirements of the PWS #08-01, paragraph 6.5 - Language Requirements and Cultural Awareness
9. I currently [ ] meet [ ] do not meet the information technology skill requirements required by PWS #08-01, paragraph 6.6 - Information Technology Skills
10. I am aware of the orientation requirements of the PWS #08-01,paragraph 6.7 - Orientation
11. I am aware of the background check required by PWS #08-01, paragraph 6.8 - Background Checks
DateLegal Signature of Nurse Candidate
Date Immunizations Completed:
Certification Statement for Performance Work Statement (PWS) #08‐01 Registered Nurse (RN)
State License No. Expiration Date
I hereby certify the below statements are full, accurate, and complete. The penalties for making false statements
State License No. Expiration Date
Date
Fetal Monitoring
Mandatory Preferred Preferred
Sheet1
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