36C25519Q0482-004.docx

FAIR OPPORTUNITY

<<PT, OT, or PTA>>, St Louis, MO VAMC

Point of contact: Kayla Haas, Contract Specialist, kayla.haas@va.gov, 913-946-1115

Work Location: ______________________________

Estimated Period of Performance: ______________________

· Period of performance is contingent upon the candidate successfully completing the VSC and credentialing process.

· The dates listed above are estimated and are not necessarily the start date.

· Key Personnel selected shall not begin performance until task order award.

Hours: _________________________________

Duty Hours: ______________________________

Other: ___________________________________

Primary Diagnosis:_________________________

Minimum two years of hospital experience or two years of ambulatory care experience: __________

Offeror shall submit the following documentation for each proposed provider in order to be considered responsive:

· Curriculum Vitae (CV)

· License &/or Certifications (include CPR and BLS)

· Availability date and length of availability for candidate

· Self-Assessment Skills Checklist

Contractor’s Name: ______________________________

Candidate’s Name: ______________________________

<<PT, OT, or PTA>> Rates:

Awarded BPA Rate: $__________/hour

Additional Discount: ___________%

Task Order Discounted Rate: $__________/hour