Certification Statement.pdf
PDF 60 KB Posted
- Attached to
- NON PERSONAL SERVICE CONTRACT FOR OPERATING ROOM NURSE Federal contract opportunity
- Solicitation number
- NNMC083122ORRN
About this file
This solicitation notice requests proposals for registered nurse services for the Operating Room Department at Northern Navajo Medical Center. The non-personal services contract would be for a base period of six months with an option to extend an additional six months. Nurses would provide services in accordance with the attached Performance Work Statement, with one nurse initially required to fill the contract. The shift hours would be 8 hours daily from 7:30am to 4pm, Monday through Friday, with on-call responsibilities also required. No government housing is available, though nearby towns offer accommodations. Candidates must be U.S. citizens holding an active, unrestricted nursing license as well as certifications in BLS, ACLS, and PALS. At least two years of relevant surgical experience is preferred. To be considered, offerors must provide their proposed hourly rate, past performance references, candidate qualifications and documentation, and confirmation of availability. The award will be made to the offer representing the best value based on price and evaluation of past performance and qualifications.
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Other files for this federal contract opportunity
| File | Type | Posted |
|---|---|---|
| OM PO.docx | DOCX document | |
| Open Market Pricing Schedule - OR RN.xlsx | XLSX spreadsheet |
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Text version
are prescribed in 18 U.S.C. 1001.
Print Name of Nurse Candidate
1. I currently [ ] meet [ ] do not meet the experience required by PWS #08-01, paragraph 6.1 - Experience.
If the experience requirement is met, attach a summary detailing employment history and job duties for the last 36 months.
2. License to practice [ ] has [ ] has not been restricted, terminated, suspended, or revoked.
If your license has been restricted, terminated, suspended, or revoked, provide a copy of the State Board of Nursing document pertaining to each occurrence.
3. I currently hold the following active, unrestricted nurse license as required by PWS #08‐01, paragraph 6.2 ‐ License/Registration (list all license):
4. I currently hold the following inactive nurse license (list all license):
5. I currently hold the following certifications as identified by the PWS #08-01, paragraph 6.3 - Certifications
Certification Expiration Certification Expiration Certification Expiration
BLS NRP
TNCC
CNOR PALS
ACLS
6. I meet the requirements of the PWS #08‐01, paragraph 6.4.1 ‐ Medical Evaluation.
My most recent medical evaluation was completed on:
7. I meet the requirements of the PWS #08‐01, paragraph 6.4.2 ‐ Immunization.
The dates of my immunizations are as follows:
a. Immunity to Rubella, Mumps, Measles MMR#1 MMR#2
b. Immunity to Hepatitis B HEP B#1 HEP B#2
HEP B#3 declination
c. History of chicken pox (varicella) disease or positive titer positive titer disease
d. Tetanus Diphtheria (Td) within the last 5 years Td
e. Documentation of receiving a TB Mantoux skin test PPD chest x-ray within the past 12 months or chest x-ray
8. I currently [ ] meet [ ] do not meet the language requirements of the PWS #08-01, paragraph 6.5 - Language Requirements and Cultural Awareness
9. I currently [ ] meet [ ] do not meet the information technology skill requirements required by PWS #08-01, paragraph 6.6 - Information Technology Skills
10. I am aware of the orientation requirements of the PWS #08-01,paragraph 6.7 - Orientation
11. I am aware of the background check required by PWS #08-01, paragraph 6.8 - Background Checks
DateLegal Signature of Nurse Candidate
Date Immunizations Completed:
Certification Statement for Performance Work Statement (PWS) #08‐01 Registered Nurse (RN)
State License No. Expiration Date
I hereby certify the below statements are full, accurate, and complete. The penalties for making false statements
State License No. Expiration Date
Date
Fetal Monitoring
Mandatory Preferred Preferred
Sheet1
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