ATTACHMENT D.3 Reference Contract Worksheet Home O2.pdf

ATTACHMENT D.3 – Reference Contract Worksheet for Offeror’s Response to Factor 1 – Experience

Reference Contract Number ______

The legal name of entity with whom the Offeror held the contract

Contract Number

Whether the contract was for in-home oxygen services, in-home ventilator services or both

A description providing details of the specific tasks the Offeror performed under that Contract

ATTACHMENT D.3 – Reference Contract Worksheet for Offeror’s Response to Factor 1 – Experience

In what geographic location the Offeror performed these services

The dates during which the Offeror performed the contract

The number of patients to whom the Offeror provided in-home oxygen services or in-home ventilator services, or both, under that contract – break out and specify numbers separately for in-home oxygen services and in-home ventilator services

Number of in-home oxygen patients served each month __________

Number of in-home ventilator patients served each month __________

Whether the provided reference contract is for services provided by the Offeror or provided by a proposed subcontractor of the Offeror’s

Whether the Offeror or its proposed subcontractor was the prime contractor or a subcontractor for that provided reference contract

The name, phone number, and email address of a person at the entity with whom the Offeror (or Offeror’s proposed subcontractor) held the contract who can verify the information the Offeror provides in the narrative description for this factor