Attachment 18 Work Sample Cover Sheet.pdf

FOPR FA2486-20-F-1001

Attachment 18

WORK SAMPLE COVER SHEET

Instructions to Offerors (ITO) Appendix 18

Fill out this form in accordance with the instructions provided at the end of this document and submit IAW the ITO

PART I: WORK SAMPLE IDENTIFICATION

CONTRACTOR NAME:

CONTRACT NUMBER:

ORDER NUMBER (if applicable):

CUSTOMER (Agency/Organization):

TOTAL PERIOD OF

PERFORMANCE, INCLUDING

OPTIONS: (MM/YYYY –

MM/YYYY or MM/YYYY – Present)

WORK SAMPLE VALUE:

TASK ORDER AGAINST A

MULTIPLE AWARD FEDERAL

GOVERNMENT CONTRACT

Yes ☐ No ☐

FUNDING AGENCY ID

Was this work sample performed as the Prime Contractor?

Yes ☐ No ☐

WORK SAMPLE IDENTIFIER

(Choose One):

Choose an item.

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

Program Manager or Contracting Officer

NAME:

TITLE:

AGENCY or CUSTOMER

PHONE

E-MAIL:

Contracting Officer’s Representative or Other Government Representative

Contracting Officer’s Representative or Other Government Representative

PART III: PROJECT DESCRIPTION (900 Character Limit)

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

VERIFICATION METHOD: (Choose one)

FPDS record (attached) ☐ Signature below by reference identified in Part II ☐

Signature below by a Program Manager, Contracting Officer, Contracting Officer’s Representative, Other Government Representative for the ordering activity constitutes acceptance of the above project information to be accurate as ordered and received by the listed entity

DATE:

SIGNATURE:

Instructions to Attachment 18 – Work Sample Cover Sheet

PART I: WORK SAMPLE IDENTIFICATION

Contractor Name: Enter the Contractor’s Name associated with this work sample.

Contract Number: Enter the Contract Number.

Order Number: Enter the Task Order Number, if applicable.

Customer: Enter the Office Symbol and Program Name this work sample supports.

TOTAL PERIOD OF PERFORMANCE, INCLUDING OPTIONS: (MM/YYYY – MM/YYYY or MM/YYYY – Present):

Work Sample Value: Enter the final or most recent total contract value of the work sample.

Task Order Against A Multiple Award Federal Government Contract: Select Yes or No Funding Agency ID: Enter the Funding Agency ID utilized for the Work Sample.

Was this Work Sample Performed as the Prime Contractor? Select Yes if the Contractor listed under Contractor Name was the Prime under the Work Sample.

Work Sample Identifier: Use the drop down box to select either WS-1, WS-2, WS-3, WS-4, WS-5. This selection should also match the tab used for each Work Sample on the Self-Scoring Worksheet, Attachment 17.

PART II: WORK SAMPLE INFORMATION/POINTS OF CONTACT

Program Manager or Contracting Officer: Provide the contact information for either the current Contracting Officer or Program Manager working the contract or the most recent Contracting Officer or Program Manager if the contract has ended. If there is no available Contracting Officer or Program Manager, leave this section blank.

Contracting Officer’s Representative or Other Government Representative: Provide the contact information for the Primary (or Alternate if Primary is not available) COR or if a COR is not available a Government Representative that would be able to assist in validation of the work sample.

Each Offeror shall provide at least two (2) Points of Contact (POCs) for each Work Sample.

PART III: WORK SAMPLE DESCRIPTION (900 Character Limit) This space is provided to allow the Offeror to present a brief synopsis of the work sample. The information provided will not be evaluated.

PART IV: WORK SAMPLE VERIFICATION METHOD (OPTIONAL)

After completing Parts I-III, provide this worksheet to the POCs listed under Part II. The POC should review the provided information from the Work Sample Cover Sheet, and only the Work Sample Cover Sheet, and their signature will verify that the information provided is accurate. If a POC is not available to sign the Cover Sheet the requested form of verification is to provide the most recent FPDS report for the contract. Part IV is optional but recommended to provide advance notice to the POCs that they may be contacted to support validation of the Work Sample.