AG-82A7-S-12-0101 Pt1.pdf
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- Frenchburg Job Corps CCC Physician Services
- Solicitation number
- AG-82A7-S-12-0101
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Solicitation AG-82A7-S-12-0101 Pt1 SF1449
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SEE ADDENDUMIS CHECKED
CODE 18a. PAYMENT WILL BE MADE BY
CODE
FACILITYCODE
17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER
OFFEROR
82A7
GOLDEN CO 80401
740 SIMMS STREET
USDA FOREST SERVICE
JOB CORPS AQM
CODE 16. ADMINISTERED BYCODE
X
X
SIZE STANDARD:
% FOR:SET ASIDE:UNRESTRICTED OR82A7
RFPIFB
10. THIS ACQUISITION ISCODE
RFQ
14. METHOD OF SOLICITATION
13b. RATING
NAICS:
SMALL BUSINESS
09/12/2012 1200 MT
08/16/2012
(303)275-5116SARAH PHERAL
(No collect calls)
INFORMATION CALL:
FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBER a. NAME
4. ORDER NUMBER3. AWARD/ 6. SOLICITATION
AG-82A7-S-12-0101
5. SOLICITATION NUMBER
SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF
1 51 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30
TELEPHONE NO.
17a. CONTRACTOR/
15. DELIVER TO
GOLDEN CO 80401
740 SIMMS STREET
USDA FOREST SERVICE
9. ISSUED BY
7.
2. CONTRACT NO.
EFFECTIVE DATE
18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW
ISSUE DATE
DELIVERY FOR FOB DESTINA-
TION UNLESS BLOCK IS
MARKED
11.
SEE SCHEDULE
12. DISCOUNT TERMS
THIS CONTRACT IS A
RATED ORDER UNDER
DPAS (15 CFR 700)
13a.
SERVICE-DISABLED
VETERAN-OWNED
SMALL BUSINESS
HUBZONE SMALL
BUSINESS
8(A)
JOB CORPS AQM
WOMEN-OWNED SMALL BUSINESS
(WOSB) ELIGIBLE UNDER THE WOSB
PROGRAM
EDWOSB
24.
AMOUNT
23.
UNIT PRICE
22.
UNIT
21.
QUANTITY
20.
SCHEDULE OF SUPPLIES/SERVICES
19.
ITEM NO.
Frenchburg Job Corps CCC - Physician Services
The Contractor will provide Physician Services to Frenchburg Job Corps CCC as detailed in the Performance Work Statement (PWS).
The anticipated contract will be for a base period + 4 one-year options which may be exercised at the Government's discretion.
Period of Performance: 10/01/2012 to 09/30/2013 Continued ...
(Use Reverse and/or Attach Additional Sheets as Necessary)
HEREIN, IS ACCEPTED AS TO ITEMS:
X
XX
DATED
TRACY L. MCGRADY
. YOUR OFFER ON SOLICITATION (BLOCK 5),
INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH
COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER
ARE
ARE
31c. DATE SIGNED
27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA
31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)
30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)
ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL
SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.
27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA
26. TOTAL AWARD AMOUNT (For Govt. Use Only)
OFFER
STANDARD FORM 1449 (REV. 2/2012)
Prescribed by GSA - FAR (48 CFR) 53.212
ARE NOT ATTACHED.
ARE NOT ATTACHED.
AUTHORIZED FOR LOCAL REPRODUCTION
PREVIOUS EDITION IS NOT USABLE
30b. NAME AND TITLE OF SIGNER (Type or print)
30a. SIGNATURE OF OFFEROR/CONTRACTOR
28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN
25. ACCOUNTING AND APPROPRIATION DATA
29. AWARD OF CONTRACT: REF.
32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE
32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:
32a. QUANTITY IN COLUMN 21 HAS BEEN
RECEIVED INSPECTED
40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER
37. CHECK NUMBER
FINALPARTIAL
36. PAYMENT
FINALPARTIAL
35. AMOUNT VERIFIED
CORRECT FOR
34. VOUCHER NUMBER33. SHIP NUMBER
COMPLETE
32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE
42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)
42b. RECEIVED AT (Location)
42a. RECEIVED BY (Print)
41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER
41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT
STANDARD FORM 1449 (REV. 2/2012) BACK
24.
AMOUNT
23.
UNIT PRICE
22.
UNIT
21.
QUANTITY
20.
SCHEDULE OF SUPPLIES/SERVICES
19.
ITEM NO.
001 Physician Services On-Center: at least 50% of total services; at least 192 estimated hours (of
384 total estimated hours)
Product/Service Code: Q201
Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
002 Mid-Level Services (Physician's Asst./Nurse
Practitioner): maximum of 50% of total services;
no more than 192 estimated hours (of 384 total estimated hours)
Product/Service Code: Q201
Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
003 Emergency Calls
Estimated: 3 hours
Product/Service Code: Q201
Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
101 Physician Services On-Center: at least 50% of total services; at least 192 estimated hours (of
Continued ...
32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE
32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE
51 2 of
ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT
NAME OF OFFEROR OR CONTRACTOR
3 51
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
AG-82A7-S-12-0101
384 total estimated hours)
Option Period 1: 10/01/2013-09/30/2014 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2013 to 09/30/2014
102 Mid-Level Services (Physician's Asst./Nurse Practitioner): maximum of 50% of total services;
no more than 192 estimated hours (of 384 total estimated hours)
Option Period 1: 10/01/2013-09/30/2014 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2013 to 09/30/2014
103 Emergency Calls
Estimated: 3 hours
Option Period 1: 10/01/2013-09/30/2014 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2013 to 09/30/2014
201 Physician Services On-Center: at least 50% of total services; at least 192 estimated hours (of 384 total estimated hours)
Option Period 2: 10/01/2014-09/30/2015 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2014 to 09/30/2015
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
Sponsored by GSA
FAR (48 CFR) 53.110
4 51
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
AG-82A7-S-12-0101
202 Mid-Level Services (Physician's Asst./Nurse Practitioner): maximum of 50% of total services;
no more than 192 estimated hours (of 384 total estimated hours)
Option Period 2: 10/01/2014-09/30/2015 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2014 to 09/30/2015
203 Emergency Calls
Estimated: 3 hours
Option Period 2: 10/01/2014-09/30/2015 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2014 to 09/30/2015
301 Physician Services On-Center: at least 50% of total services; at least 192 estimated hours (of 384 total estimated hours)
Option Period 3: 10/01/2015-09/30/2016 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2015 to 09/30/2016
302 Mid-Level Services (Physician's Asst./Nurse Practitioner): maximum of 50% of total services;
no more than 192 estimated hours (of 384 total estimated hours)
Option Period 3: 10/01/2015-09/30/2016 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
5 51
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
AG-82A7-S-12-0101
Period of Performance: 10/01/2015 to 09/30/2016
303 Emergency Calls
Estimated: 3 hours
Option Period 3: 10/01/2015-09/30/2016 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2015 to 09/30/2016
401 Physician Services On-Center: at least 50% of total services; at least 192 estimated hours (of 384 total estimated hours)
Option Period 4: 10/01/2016-09/30/2017 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2016 to 09/30/2017
402 Mid-Level Services (Physician's Asst./Nurse Practitioner): maximum of 50% of total services;
no more than 192 estimated hours (of 384 total estimated hours)
Option Period 4: 10/01/2016-09/30/2017 (Option Line Item) Product/Service Code: Q201 Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2016 to 09/30/2017
403 Emergency Calls
Estimated: 3 hours
Option Period 4: 10/01/2016-09/30/2017 (Option Line Item) Product/Service Code: Q201 Continued ...
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
6 51
CONTINUATION SHEET
REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF
(A) (B) (C) (D) (E) (F)
AG-82A7-S-12-0101
Product/Service Description: MEDICAL- GENERAL
HEALTH CARE
Period of Performance: 10/01/2016 to 09/30/2017
NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)
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