2.1.1- ATTACHMENT 6 – Prior Experience Questionnaire 70B06C26R00000017.docx

70B06C26R00000017- ATTACHMENT 6- Prior Experience Questionnaire

CBP/HRM/Medical Support Services Prior Experience Questionnaire Instructions:

Complete this questionnaire by providing demographic and corporate experience information for your firm. You may provide up to three (3) reference projects (ongoing or completed within the last three years) that demonstrate relevant experience performing projects similar in size and scope to the requirements outlined in the SOW. Projects should demonstrate experience with large-scale, multi-site medical, fitness, and drug testing services for federal law enforcement, military, or first responder organizations. Attach additional sheets if necessary.

Firm Information Firm’s Name and Address:

Name and Title of Representative:

Phone: ___________________________ Fax: ___________________________ E-mail Address: _______________________________________________________ Labor Categories Provided Under Projects:

(List labor categories such as Program Manager, Medical Review Officer, Laboratory Director, Lead Reviewing Physician, Mental Health Consultant, Vision Consultant, Specimen Collector, Test Administrator, etc.)

If teaming with another firm(s), list their name(s) and address(es):

· Firm 1 – Name: _____________________________ Address: _____________________________

· Firm 2 – Name: _____________________________ Address: _____________________________ (If more than two partners are proposed, attach additional sheets.)

Has this team worked together previously? □ Yes □ No

Contract/Order Information Contract/Order #: ________________________________________ Contract Period: _________________________________________

Reference Projects Project 1

· Project Name and Location:

· Nature of Work Performed:

(Describe scope, e.g., nationwide medical exams, fitness testing, drug testing, compliance with HHS/DOT guidelines, data security, web-based reporting, etc.)

· Customer Name and Address:

· Firm’s Project Manager Name and Phone Number:

· Period of Performance and Percentage Complete:

· Estimated or Final Value:

· Key Deliverables/Features:

(Check all that apply and provide brief details)

· □ Pre-employment and post-employment medical examinations

· □ Fitness-for-duty evaluations (FFDE)

· □ Drug-free workplace program administration (HHS-certified)

· □ Laboratory and Medical Review Officer (MRO) services

· □ Web-based scheduling and reporting platforms

· □ Compliance with HIPAA, FISMA, NIST, and DHS security requirements

· □ Nationwide/multi-site service delivery (list number of sites/states)

· □ Experience with CBP, other DHS components, or similar agencies

Project 2 (Repeat fields as above)

Project 3 (Repeat fields as above)

Summary of Relevant Experience Describe how your firm’s experience demonstrates the ability to:

· Scale operations to support high-volume, nationwide medical, fitness, and drug testing services for federal law enforcement or similar organizations.

· Maintain compliance with all applicable federal regulations (e.g., HHS, DOT, HIPAA, FISMA, NIST, DHS/CBP directives).

· Provide secure, web-based data systems for scheduling, reporting, and document management.

· Recruit, credential, and manage a network of healthcare professionals and collection sites.

· Meet strict timelines and deliverables as outlined in the SOW.

(Attach additional narrative if necessary, but keep responses concise and focused on SOW requirements.)