4. Attachment C Data Collection Form.pdf

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Attached to
Parent BPAs: CICP Vocational Counselor FY25-30
Solicitation number
75R60225Q00082
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This document is a Data Collection Form for the Countermeasures Injury Compensation System (CICP) Parent Blanket Purchase Agreements (BPAs) for Life Care Planners covering Fiscal Years 2025-2030. The form requires detailed personal and professional information from potential contractors, including name, Social Security Number, date of birth, medical specialty, taxpayer identification number, and Unique Entity ID Number.

The form instructs applicants to provide contact information and verifies System for Award Management (SAM) registration status. It mandates the use of a secure mail system called SEFT for document transmission, with only limited paper file exceptions. Applicants must provide multiple contact numbers and a mailing address, highlighting the comprehensive contact and identification requirements for potential life care planners under this federal contract opportunity.

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Other files

File Type Posted
7. 75R60225Q00082 Amend 0001.pdf PDF
7. Attachment F Proposed Pricing.pdf PDF
5. Attachment D NonDisclosure Agreement.pdf PDF
3. Attachment B Past Performance Questionnaire.pdf PDF
6. Attachment E Contract Clauses.pdf PDF
2. Attachment A Statement of Work Vocational Counselor.pdf PDF
1. RFQ 75R60225Q00082.pdf PDF

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Attachment C - Data Collection Form

COUNTERMEASURES INJURY COMPENSATION SYSTEM

(CICP) PARENT BPAs: CICP LIFE CARE PLANNER FY25-30

Data Collection Form

General Instructions:

1. Type or print ALL information clearly, including Not Applicable (N/A) blanks.

2. We are requiring everyone to receive case documents via a secure mail system called SEFT. We will only send paper files on a very limited basis.

3. Please provide a telephone number or numbers where you prefer to be contacted.

Name: ____________________________________ SSN: ____________________________________

DOB: ____________________________________ Medical Specialty: ___________________________

Taxpayer Identification Number (If different from SSN):

Unique Entity ID Number: ____________________________________________

Registered in SAM: Yes / No

If yes, SAM Expiration Date: _____________________

Mailing Address:

E: Mail Address: _______________________________

Telephone Number(s):

Office: ____________________ Home: ____________________ Cell: ____________________

File details come from the government source that posted it. Updated .