Certification Statement.pdf
PDF 60 KB Posted
- Solicitation number
- NNMC12072022OBGYN-3
About this file
This solicitation notice requests proposals for registered nurse services at Northern Navajo Medical Center in Shiprock, New Mexico. The Indian Health Service seeks to fill three vacant positions for registered nurses in the OB/GYN Inpatient department under a non-personal services contract. The period of performance is six months for the base period and an option period. Quotes are due by November 30, 2022 and must include the all-inclusive hourly rate, past performance history, qualifications and licensure documentation for proposed candidates, and proof of liability insurance. The NAICS code is 561320 and the small business size standard is $30 million. The evaluation criteria are price, past performance, qualifications, and interviews to verify candidate understanding and qualifications.
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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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