3-Certification Statement.pdf
PDF 60 KB Posted
- Solicitation number
- NNMC1019ICUERAMBU
About this file
This document contains a solicitation notice for a non-personal service contract for registered nurse services. The Indian Health Service is seeking proposals for registered nurses to provide services at the Northern Navajo Medical Center in Shiprock, New Mexico and the 4 Corners Regional Health Center in Red Mesa, Arizona. The base period of performance is six months from date of award with an option to extend for an additional six months. One position is available for an ICU nurse and one for an ER nurse at Northern Navajo Medical Center, and one ambulatory care nurse position is available at 4 Corners Regional Health Center. Proposals are due by October 19, 2022 and must include the hourly rate, past performance information, candidate qualifications and licensures/certifications, availability, and proof of liability insurance for consideration. The contract will be awarded based on best value determined by price and evaluation of past performance and qualifications.
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Other files
| File | Type | Posted |
|---|---|---|
| 1 Terms and Conditions PWS Wage Determination.pdf | ||
| 2-Pricing Schedule.xlsx | XLSX spreadsheet |
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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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