D.1 Required Compliance Checklist.docx
DOCX document 21 KB Posted
- Solicitation number
- 36C25027R5412
About this file
This is a Required Compliance Checklist document for a Non-Emergency Medical Transportation (NEMT) contract solicitation. The checklist is associated with solicitation number 36C25027R5412 for V226--NEMT services at the Cleveland Veterans Affairs Medical Center (VAMC), with a follow-on base 2 start date of February 1, 2027. The contracting activity is the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 10 (VISN 10). This document serves as a template or administrative tool to ensure that prospective contractors and/or the contracting officer verify compliance with specified requirements throughout the proposal submission and evaluation process. The checklist format indicates it is designed to systematically track adherence to contractual, regulatory, and administrative obligations rather than to establish substantive service or product requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C25027R5412.docx | DOCX document | |
| D.6 Statement of Start Date Confirmation updated.docx | DOCX document | |
| D.3 Statement of FAR 52.222-41 - Statement of DoL WD Compliance.docx | DOCX document | |
| D.5 Past Performance Questionnaire updated 7.6.2026.docx | DOCX document | |
| D.2 WD 2015-4727 Rev 31 Cleveland 22 August 2026.docx | DOCX document | |
| D.4 Statement of FAR 52.219-14 Limitations on Subcontracting Compliance.docx | DOCX document |
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D.1 COMPLIANCE CHECKLIST – REQUIRED FOR CONTRACTORS TO COMPLETE
All sections below must be completed with accurate information. If an item is not applicable “N/A.”
1. Contractor Information Name of Prime Contractor
DBA - Doing Business As (If applicable)
SAM UEI
Cage Code
Street Address of Prime Contractor
City, State & Zip
Primary POC – Prime Contractor
Phone Number
Years of V226 or 485910 Experience
2. SBA Certifications (Social-Economic Statuses) and active expiration date(s) of the PRIME ONLY.
Certification Mark (x) if held
| SBA Certification |
| Active Expiration Date |
Service Disabled Veteran Owned SB (SDVOSB)
Veteran Owned SB (VOSB)
Economically Disadvantaged Woman Owned SB (EDWOSB)
Woman Owned SB (WOSB)
8(a) Small Business (8(a))
HUBZone (HUB)
Small Disadvantaged Business (SDB)
3. The following are required based on the requirement document or submittals found on section E.1 FAR 52.212-1 located on page 88 of the RFQ. Each required document shall be submitted under the PDF with the title show as below.
Vendor Name – Technical I - 36C25027R5412 ☐ SF 1449, Most updated. Must filled out and be signed ☐ SF 30, Amendment(s) must be signed. Each must be acknowledged on Table B.1 of RFQ.
| ☐ | Statement of FAR 52.229-11 section E.5 page 95 of RFP. Completed in its entirety and signed. |
| ☐ | Statement of FAR 52.209-7 section E.4 page 94 of RFP. Completed in its entirety and signed. |
Vendor Name – Technical II - 36C25027R5412
| ☐ | D.3 Statement of FAR 52.222-41 Statement of DoL WD Compliance. Completed in its entirety and signed. |
| ☐ | D.4 Statement of FAR 52.219-14 Statement of Limitation of Subcontracting Compliance. Completed in its entirety to include occupational code(s) and occupational title. It must be signed. |
| ☐ | D.6 Start Date Confirmation. Completed and signed. |
| ☐ | A printout of an Active Emergency, Medical, Fire, and Transportation Service License in the Prime contractor’s name |
| ☐ | Proof of insurance. Meets limitations set in section C.6 of RFQ. |
Vendor Name – Technical III - 36C25027R5412
| ☐ Management, Staffing and Training Plan |
| ☐ Fleet Plan |
| ☐ Contingency Plan |
| ☐ Quality Control Plan |
Vendor Name – Past Performance -36C25027R5412 ☐ Past performance (References, Questionnaires, or CPARS)
4. I understand that the above lists must be completed and checked off. Any items not completed or checked off will render the package non-compliant and exclude it from consideration in the competition for award of the contract for NEMT service at Cleveland VAMC.
Signature: _____________________________________________________________________
Name: _________________________________________________________________________ Dated: _________________________________________________________________________ Title: ___________________________________________________________________________ Company: ______________________________________________________________________
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