D.4 KEY PERSONNEL.docx
DOCX document 15 KB Posted
- Solicitation number
- 36C24225R0092
About this file
The document is a Key Personnel Roster template for prescreening candidates for a medical services contract at the James J. Peters Healthcare System in the Bronx, NY. The roster is designed for the Request for Quote (RFQ) number 36C24225R0092, which seeks Interventional Radiology Physician Services for the Department of Veterans Affairs Veterans Health Administration.
The template requires detailed information for up to four candidates, including full name, residence address, contact information, professional credentials, and compliance documentation. Specific required fields include NPI number, DEA number, state license details, medical liability insurance expiration date, credentialing status, and a copy of the National Criminal History Check (NCHC). This comprehensive roster appears to be a critical component of the candidate vetting process for the long-term medical services contract at the Bronx VA Medical Center.
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Other files
| File | Type | Posted |
|---|---|---|
| 36C24225R0092 0002.docx | DOCX document | |
| 36C24225R0092 0001.docx | DOCX document | |
| S02 Wage Determination-Bronx.pdf | ||
| 36C24225R0092_1.docx | DOCX document | |
| D.1 QASP.pdf | ||
| D.2 ORG_CONFLICT_CERT.pdf | ||
| D.6 OTHER THAN CERTIFIED COST AND PRICING.xlsx | XLSX spreadsheet | |
| D.5 INFORMATION SECURITY RULES OF BEHAVIOR.pdf | ||
| D.3 IMMIGRATION AND NATIONALITY ACT.pdf |
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Text version
D.4 Key Personnel Roster – Candidate’s for prescreening determination James J. Peters Healthcare System – Bronx NY VAMC
RFQ: 36C24225R0092
Candidate Number 1:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 2:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 3:
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Candidate Number 4
1. Full Name:
2. Residence address:
3. Cell Phone:
4. Email address:
5. NPI number:
6. DEA number:
7. State License and Date:
8. Medica Liability Insurance exp Date:
9. Credentialed and Privileged: Yes or No
10. National Criminal History Check (NCHC) copy provided if one has been conducted in the past: Yes or NO, copy if obtained required Add additional candidate requirements if applicable below!
File details come from the government source that posted it. Updated .