36C25518R0327-0001000.docx

Section D, Attachment D.5, HCHV Safe Haven Services, 36C25518R0327

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2.

AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE

OF PAGES

10A. MODIFICATION OF

CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning ___ _______ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV.

11/2016) is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO:

Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITE M 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES

SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR

43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes r eference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS

ENTERED INTO

PURSUANT TO AUTHORITY OF:

D. OTHER

BY

Contractor

16C. DATE SIGNED

14.

DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME

AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS

OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) 06-18-2018 n/a 36C255 Department of Veterans Affairs Network Contracting Office (NCO) 15 3450 S 4th Street Trafficway Leavenworth KS 66048 36C255 Department of Veterans Affairs Network Contracting Office (NCO) 15 3450 S 4th Street Trafficway Leavenworth KS 66048 To all Offerors/Bidders

36C25518R0327

X x x x The purpose of this amendment pertaining to RFP 36C25518R0327 is to notify all Interested Contractors that Attachment D.5 Past Performance Questionaire that was submitted with the original Solicitation will be replaced by the questionnaire included in this Amendment.

All Past Performance questionaires are to be submitted along with the Technical Proposal IAW Section E, 52.212-2.

PEGGY BECKER

CONTRACTING OFFICER

CONTINUATION PAGE

PAST PERFORMANCE QUESTIONNAIRE

1. The Contractor identified below has requested that you complete a past performance questionnaire on their behalf. This questionnaire will be used by the Contracting Officer to assess the likelihood that the Offeror will perform Healthcare for Homeless Veterans (HCHV) Low Demand Safe Have (LDSH) services for those hard-to-reach chronically homeless Veterans with mental illness and/or substance abuse problems for Kansas City and Leavenworth VAMCs. Your prompt completion and return of this questionnaire is greatly appreciated.

CONTRACTOR NAME _________________________________________

REFERENCED CONTRACT # _________________________________________

2. Background. The Kansas City and Leavenworth Veteran’s Hospital, have a need for Healthcare for Homeless Veterans Low Demand Safe Haven Services for eligible Veterans that meet the HCHV requirements IAW 38 USC Part 63 2031 and VHA HCHV Handbook 1162.09. The contractor shall furnish qualified providers, key personnel, facility, food service, transportation, case management and outreach services and administrative functions to fulfill the new requirement for both locations.

3. GENERAL INFORMATION: (Completed by Reference of Contractor being evaluated)

Name of Government or Commercial Organization:______________________________ Address:_________________________________ Contract Number:______________________________ Brief Description:_________________________________________________________

Contractor Performed as: |_|Prime Contractor |_|Sub-Contractor Dates of Performance (if current include expiration):_____________________________ Total Value of Contract:__________________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:_________________________________________________________________ Any contract discrepancy reports filed? Circle YES or NO If yes, brief explanation: ________________________________________________________________

Point Of Contact/Contracting Officer’s Representative:________________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:____________________________

Please use the below matrix to answer questions relating to performance using the following template.

Please evaluate the past performance using only the following ratings without variation. If the rating is Excellent, Good, Marginal or Unsatisfactory, please provide additional information in the appropriate block or in the remarks section of this form.

“E” = Excellent = Performance greatly exceeded the contract requirements

“G” = Good = Performance exceeded the contract requirements

“S” = Satisfactory = Performance met the contract requirements

“M” = Marginal = Performance met the minimum contract requirements but some material aspects of the contractor’s performance were less than satisfactory

“U” = Unsatisfactory = Performance was poor and/or did not satisfy contract requirements

Please write in “not applicable” or “neutral” if unable to rate a certain question. For any E, G, M, or U rating, please provide a short summary explanation of rating.

Q1. Did the contractor provide HCHV Services and Mental Health and/or Substance Services? If no, please provide a short description of the type of services provided.

Yes or No

Q2. To what extent did the contractor comply with overall contract requirements?

E G S M U

Q3. How successful was the Contractor in filling all requirements?

E G S M U

Q4. How would you rate the quality of the Staff provided by this Contractor in terms of technical competence, reliability, and demeanor with patients and staff?

E G S M U

Q5. To what extent was the Contractor able to meet unexpected and short notice changes and/or requirements (e.g. unexpected shift vacancies, training requirements).

E G S M U

Q6. How would you rate the Contractor’s administrative staff as pertains to communication with your organization’s key personnel, their ability to maintain Case Management files, track all appointments and transportation needs, adhere to billing and invoicing processes, and overall contract management?

E G S M U

Q7. Were there any critical incidences that needed being reported that resolved in suspension of services or nonpayment? If yes, please explain.

Yes No

Q8. Would you recommend using the Contractor for future services and/or to others for the Contractor being evaluated? If no, please explain:

Yes No

Q9. Additional Comments pertaining to contractor performance:

Printed Name & Signature of Evaluator

Date

Please return completed questionnaire along with the Technical Proposal. For any questions, please call Kathleen Sciortino at 315-795-8396 or kathleen.sciortino@va.gov.