Attachment_2_-_Personnel_Qualifications_Sheet.pdf

FA5270-17-T-0004

Attachment 2

PERSONNEL QUALIFICATIONS SHEET (PQS) – DRHA Provider

1. Every item on the Personal Qualifications Sheet must be addressed. Please sign and date where indicated. Any additional information required may be provided on a separate sheet of paper (indicate by number and section the question(s) to be addressed).

2. The information provided will be used to determine personnel ranking.

3. After contract award, all of the information provided may be verified during the credentialing process as applicable. At that time, you may be required to provide varying documentation. If you submit false information, the following actions may occur:

a) Your contract may be terminated for cause. This action may initiate the suspension and debarment process, which could result in the determination that you are no longer eligible for future Government contracts.

b) You may lose your clinical privileges. If that occurs, an adverse credentialing action report will be forwarded to your State licensing bureau and the National Practitioners Databank.

4. Personal and Practice Information:

Yes No

1. Have you ever been the subject of a malpractice claim? ___ ___

(indicate final disposition of case in comments)

2. Have you ever been a defendant in a felony or misdemeanor case? ___ ___

(indicate final disposition of case in comments)

3. Has your license to practice or DEA certification ever been revoked ___ ___ or restricted in any state?

4. Have you ever been arrested for or charged with a crime involving a child? ___ ___

5. a. Are you a U.S. Citizen? ___ ___

b. If yes, do you hold dual citizenship or a passport from a foreign country? ___ ___

If any of questions 1 through 4 and 5b above is answered "yes" attach a detailed explanation. Specifically address the disposition of the claim or charges for numbers 1 through 4 above, and the State of the revocation for number 3 above. If you hold a dual citizenship or have a passport issued from a foreign country, address which country the dual citizenship is held and/or which foreign country has issued you a passport.

PRIVACY ACT STATEMENT

Under 5 U.S.C. 552a and Executive Order 9397, the information provided on this page and the Personal Qualifications

Sheet is requested for use in the consideration of a contract; disclosure of the information is voluntary; failure to provide information may result in the denial of the opportunity to enter into a contract.

_________________________ _____________(mm/dd/yy)

(Signature) (Date)

I. General Information

Name: SSN:______________

Last First Middle

Date of Birth: ___________

Address: ___________________________________

Phone: ( ) ________________ Email: ________________________

Medical Information YES NO

1. Do you have any physical or mental impairment that could limit your clinical practice? ___ ___

2. Have you been hospitalized for any reason during the past 5 years? ___ ___

3. Are you currently receiving or have you ever received formal mental health therapy or treatment? ___ ___

4. Are you currently receiving, or have you in the past ever received, treatment or therapy for any alcohol or drug-related condition? ___ ___

5. Have you ever been unlawfully involved in the use of controlled substances? ___ ___

If any of questions 1 through 5 above is answered, "yes”, attach a detailed explanation.

II. State Professional Licensure (License must be current, valid, and unrestricted) (Section D, Item 1):

________ (State) Date of Expiration: _____________ (mm/dd/yy)

III. Board Certification(s):

Title of Certification Date of Certification (mm/dd/yy)

Title of Certification Date of Certification (mm/dd/yy)

IV. Professional Employment: List your current and preceding employers. Provide dates as month/year.

Name and Address of Present Employer From To

(1) _______________________________________________________

From To

(2) _______________________________________________________

(3) _______________________________________________________

(4) _______________________________________________________

(5) _______________________________________________________

(6) _______________________________________________________

Are you are currently employed on a contract (public or private)? If so where is your current contract and what is the position? ___________________________________________

When does the contract expire? _____________________________________

V. I am currently certified in BLS or will be certified in BLS prior to contract start-date.

YES_____________ NO _____________

VI. I am currently certified in ACLS or will be certified in ACLS prior to contract start-date.

YES_____________ NO _____________

VII. Professional Recommendations/Clinical Competency

Provide two letters of recommendation from current or previous supervisors attesting to your personal clinical experience and professional skills as a practitioner in your discipline. These letters must be dated and shall include the name, title, phone number, address and signature of the individual providing the recommendation. The letters must have been written within the 2 years preceding submission of your proposal.

VIII. Continuing Education Hours within the preceding 3 years (Factor for Award):

Title of Course From To CE Hours

IX. Additional Information:

Provide any additional information you feel may enhance your ranking based on Section E. Factors to be used in a

Contract Award Decision, such as your resume, curriculum vitae, commendations or documentation of any awards you may have received, etc.

I hereby certify the above information to be true and accurate:

(mm/dd/yy)

(Signature) (Date)

Enclosures:

Copy of Professional Education Degree(s)

Copy of all medical licenses held within the preceding 10 years

Copy of relevant continuing education certificates (see VIII above)

Name (Printed)