Attachment J.17 - Change_Request_form.docx
DOCX document 73 KB Posted
- Solicitation number
- 75D301-22-R-72142
About this file
This change request form outlines proposed changes to an existing contract to provide clinical services to the World Trade Center Health Program. Key details include that the contractor seeks additional funding to expand infrastructure and software capabilities to meet increased capacity requirements, such as additional hardware, network connectivity, and clinical data management systems. The change request identifies associated risks and mitigation strategies. If approved, the contractor would provide updated deliverables, work schedules, and effort estimates. The existing contract was awarded in 2011 between the National Institute for Occupational Safety and Health and an unnamed contractor to provide health services to 9/11 responders and survivors consistent with Zadroga Act requirements.
The related federal opportunity solicits applications to establish and operate World Trade Center Clinical Centers of Excellence through cost-reimbursement contracts of 5-8 years. Services include contract management, quality assurance, member services and outreach, care coordination, program communications, healthcare delivery, coordination of other health insurance benefits, and collection of clinical and operational data. Questions must be submitted by the deadline to the identified point of contact using the provided template. Award will use a best value tradeoff method.
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Text version
Change Control Request Change Request #1 Significant Change Request (with funding) # Contract No.
Contractor name and address:
Contractor point of contact:
Table of Contents
| INTRODUCTION | 3 |
| SCOPE OF SERVICES | 3 |
| APPROACH / PROPOSED CHANGES | 4 |
| INFRASTRUCTURE & CAPACITY REQUIREMENT | 4 |
| HARDWARE | 4 |
| SOFTWARE | 4 |
| NETWORK CONNECTIVITY | 4 |
| KEY RISKS, MITIGATION AND ASSUMPTIONS | 4 |
| RISKS | 4 |
| MITIGATION | 4 |
| ASSUMPTIONS | 4 |
| DELIVERABLES, ROLES & RESPONSIBILITIES | 5 |
| WORK ORDER SCHEDULE | 5 |
| EFFORT ESTIMATE & PRICING | 5 |
| REFERENCES | 5 |
| KEY CONTACTS | 5 |
| APPROVALS | 5 |
- 6 -
1. Introduction
Since its inception in July 1, 2011 the World Trade Center (WTC) Health Program has contracted with _________to provide __________________________services.
2. Approach / Proposed Changes
3. Infrastructure & Capacity requirement
3.1 Hardware
3.2 Software
4. Key Risks, Mitigation and Assumptions
· Risk:
· Mitigation:
· Assumption:
5. Deliverables, Roles and Responsibilities
6. Work Order Schedule Include work breakdowns and timeline.
7. Effort Estimate & Pricing
8. References
9.
10. Key Contacts
| Vendor Contact |
| Designation |
| Email, Phone & Fax No |
| NIOSH Contact |
| Designation |
| Email, Phone & Fax No |
11. Approvals
This Work Order version 1.0 is agreed and accepted by:
Contractor: ……………………………. NIOSH/WTC Health Program
By:
Name: Name:
| Title: | Title: |
| Date: | Date: |
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