D.31 - Reference Contract Worksheet.docx
DOCX document 22 KB Posted
- Solicitation number
- 36C26224R0118
About this file
This is a Reference Contract Worksheet template that offerors must complete as part of Factor 1 - Experience for solicitation 36C26224R0118. The worksheet requires detailed information about previous contracts for establishing and/or operating Community-Based Outpatient Clinics (CBOCs) providing primary care services to adult patients aged 18 and older. Required information includes the contract number, contracting entity name, specific tasks performed in establishing the CBOC (site acquisition, build-out, staffing), medical services provided during operation (primary care, telehealth, etc.), geographic location, contract dates, monthly patient volume, prime/subcontractor status, and a point of contact who can verify the information.
The worksheet is related to a VA solicitation for CBOC services in Alamogordo, New Mexico, which seeks primary care and mental health services for veterans. Offerors must demonstrate relevant past performance in either establishing, operating, or both establishing and operating similar CBOCs through completion of this form. The template allows for expansion but not modification of the core requirements and examples provided.
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Text version
D.31 Reference Contract Worksheet - 36C26224R0118 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 ages 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.
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