36C25918R0573-005.docx

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Copy of (M) 635-Inpatient Dialysis: ATTN Kevin Pollard (VA-18-00082608)
Solicitation number
36C25918R0573
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This document contains a past performance reference template for a federal contractor and details of a related federal contract opportunity notice. The template requires contact information for up to three past performance references involving similar work as prime or subcontractor. Details must include organization, contract number, brief description of work, dates of performance, total cost, and point of contact.

The related opportunity notice is for inpatient dialysis services at the Oklahoma City VA Medical Center. A fixed price indefinite quantity contract using a capitated rate reimbursement method is proposed, with an estimated NAICS code of 621492. The solicitation will be available on July 13, 2018 with proposals due August 10, 2018. All questions must be submitted by email to the listed point of contact by July 23, 2018, and answers will be provided by amendment. No electronic submissions will be accepted. The opportunity is with the Department of Veterans Affairs Veterans Health Administration VISN 19.

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36C25918R0573 ATTACHMENT D - PAST PERFORMANCE REFERENCES.docx

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Attachment D

PAST PERFORMANCE REFERENCES

REFERENCE 1:

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 Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________ Comments:_____________________________________________________________________________________________________________________________________

REFERENCE 2:

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 Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________ Comments:_____________________________________________________________________________________________________________________________________

REFERENCE 3:

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 Cost of Contract:__________________Award/Incentive/Deduction_____________ Any terminations for cause or default? Circle YES or NO If yes, brief explanation:___________________________ Point Of Contact/COR:____________________________ Title:___________________________________ Telephone Number:____________________________ Point of Contact’s email address:______________________ Comments:_____________________________________________________________________________________________________________________________________

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