Attachment 2 - Past Performance Self Certification Worksheet.docx

This is a Past Performance Self-Certification Worksheet for vendors responding to a Request for Quote (RFQ) for Extracorporeal Shock Wave Therapy (ESWT) Systems. The worksheet is designed for offerors to self-certify their qualifications and performance history regarding ESWT systems, specifically Storz Shockwave Therapy Systems, provided to commercial or government clients within the past three years. The solicitation is issued by the Defense Health Agency for Winn Army Community Hospital and Martin Army Community Hospital under solicitation number HT940626QE114, conducted as full and open competition for commercial items in accordance with FAR 12.2.

Offerors must complete vendor information sections including company name, CAGE Code/UEI, and point of contact details, followed by self-certification responses addressing three critical compliance areas: any FDA Class I, II, or III recalls within the past three years; any infection control issues, FDA observations, or customer complaints related to ESWT devices or applicators; and any early contract terminations for cause. For each affirmative response, vendors must provide detailed narratives explaining the cause and corrective actions taken. The worksheet must be completed and signed by an authorized representative certifying that all information provided is current, accurate, and complete.