D. 1 REFERENCE CONTRACT WORKSHEET.docx
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- Attached to
- Q201--664 - 36C262-24-AP-4043 VASDHS New Escondido CBOC Procurement _ Base plus 9 Option Years
- Solicitation number
- 36C26224R0121
About this file
This document is a Reference Contract Worksheet for Offeror's response to Factor 1 - Experience under Solicitation No. 36C26224R0121 for the establishment and operation of a Community-Based Outpatient Clinic (CBOC) providing primary care services to an adult population age 18 and older.
The worksheet requires the offeror to provide details on a reference contract, including the legal name of the contracting entity, the contract number, whether the contract was for establishing, operating, or both establishing and operating a CBOC, a narrative describing the specific tasks performed to establish the CBOC and the medical services provided while operating it, the geographic location, the dates of performance, the average number of adult patients served per month, and whether the offeror or a proposed subcontractor held the reference contract. The offeror must also provide contact information for a person who can verify the information provided.
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Text version
D.1 Reference Contract Worksheet - 36C26224R0121 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);
| In what geographic location the Offeror (or the Offeror’s proposed subcontractor) performed these services. |
| (examples: Santa Fe, NM; Long Beach, CA) |
The dates during which the Offeror (or the Offeror’s proposed subcontractor) performed the contract;
The average number per month of adult patients age 18 and older to whom the Offeror (or the Offeror’s proposed subcontractor) provided Primary Care services to under that contract;
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.
File details come from the government source that posted it. Updated .