D.1 REFERENCE CONTRACT WORKSHEET - ATTACHED.docx
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- Attached to
- Q201-- VASDHS Primary Care El Centro CBOC Federal contract opportunity
- Solicitation number
- 36C26225R0004_1
About this file
This document is a Reference Contract Worksheet to be used by offerors in responding to Factor 1 - Experience for Solicitation 36C26225R0004. It requires offerors to provide details on a reference contract for establishing and/or operating a Community-Based Outpatient Clinic (CBOC) providing primary care services to an adult population. Specifically, offerors must provide information on: the contract holder, contract number, services performed to establish and operate the CBOC, geographic location, contract dates, average monthly billable roster, whether the offeror or a proposed subcontractor performed the work, and the prime/subcontractor status. A point of contact at the contract entity is also required to verify the information provided. This worksheet is a component of the solicitation for establishing and operating a CBOC in El Centro, California, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22.
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Text version
D.1 Reference Contract Worksheet - 36C26225R0004 D. 1 Reference Contract Worksheet for Offeror’s Response to Factor 1 – Experience Offeror’s shall use this form for their response to Factor 1 – Experience. The form may be expanded but NOT edited except for the examples in italics which shall be removed.
Reference Contract
| 1.The legal name of entity with whom the Offeror (or the Offeror’s proposed subcontractor) held the contract; |
| (examples: New Mexico Veterans Affairs Healthcare System; Long Beach Community Hospital, Los Angeles Department of Health Services) |
2.The contract number;
3.Whether the contract was for establishing, or operating, or both establishing and operating a CBOC providing Primary Care services to an adult population age 18 and older. (check one as applicable)
____ Contract was for establishing a CBOC providing Primary Care Services to an adult population age 18 and older.
____ Contract was for operating a CBOC providing Primary Care Services to an adult population age 18 and older.
____ Contract was for both establishing and operating a CBOC providing Primary Care Services to an adult population age 18 and older.
4.A narrative describing the specific tasks the Offeror (or Offeror’s proposed subcontractor) performed to establish the Primary Care CBOC under that contract (e.g., site acquisition; build-out; staffing; clinic opening, etc.);
5. A narrative describing the specific medical services the Offeror (or Offeror’s proposed subcontractor) performed while operating the Primary Care CBOC under that contract (e.g., primary care, telehealth, audiology, pharmacy, other specialty services);
6. In what geographic location the Offeror (or the Offeror’s proposed subcontractor) performed these services.
(examples: Santa Fe, NM; Long Beach, CA)
7. The dates during which the Offeror (or the Offeror’s proposed subcontractor) performed the contract;
8. The average monthly billable roster under the reference contract that the Offeror (or the Offeror’s proposed subcontractor) invoiced for Primary Care Services under that contract;
9. Whether the provided reference contract is for services provided by the Offeror or provided by a proposed subcontractor of the Offeror’s. If the claimed experience is for a proposed subcontractor, provide the full legal name of the proposed subcontractor;
10. Whether the Offeror or its proposed subcontractor was the prime contractor or a subcontractor for that provided reference contract;
11. 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.
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