PHAP_CDRL_A003.pdf

PDF 195 KB Posted Sep 4, 2019

Attached to: Psychological Health Advocacy Program Services
Solicitation number: FA664319RA003
Issued by: Department of the Air Force Reserve Command

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CDRL A003

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DD FORM 1423-1, FEB 2001

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

PREVIOUS EDITION MAY BE USED.

Form Approved OMB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services and Communications Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP ________ TM _______ OTHER

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.) 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

7. DD 250 REQ

8. APP CODE

9. DIST STATEMENT

REQUIRED

10. FREQUENCY

11. AS OF DATE

12. DATE OF FIRST SUBMISSION

13. DATE OF SUBSEQUENT

SUBMISSION

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

Draft Final

Reg Repro

15. TOTAL

16. REMARKS

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

Page of Pages

1_DATA_ITEM_NO: A003

2_TITLE_OF_DATA_ITEM:

Data Report

3_SUBTITLE: Document Shipping

4_AUTHORITY_Data_Acquisit: DI-MISC-80678

5_CONTRACT_REFERENCE: PWS 1.4.10.3, 1.4.11.1, 1.4.11.2

6_REQUIRING_OFFICE: AFRC/A1R Yellow Ribbon

7_DID_250_REQ:

8_APP_CODE:

DIST_STATEMENT: A

10_FREQUENCY: Monthly

11_AS_OF_DATE:

12_DATE_OF_FIRST_SUBMISSI: See Block 16

13_DATE_OF_SUBSEQUENT_SUB: See Block 16

addressee1: CO

draft1: 1

reg1: 1

repro1:

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draft2: 1

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total_draft: 2

total_repro: 0

16_REMARKS: See PWS 1.4.10 - 1.4.10.3 PHAP Case files for full details.

See PWS 1.4.11. - 1.4.11.2 Customer Satisfaction Survey

The Contractor shall ensure all files are handled IAW Health Insurance Portability and Accountability Act (HIPAA). The Contractor shall review all files for completeness prior to sending them to the AFRC COR.

Hard copies of closed files will be mailed to AFRC COR once files have been reviewed and closed.

Closed files will include all intake forms, progress notes, emails, text messages, referral sources, case closure forms,and Customer Satisfaction Survey

Block 12 - First submission 30 days ARO

Block 13 - Subsequent submissions to occur at the end of each following month.

17_PRICE_GROUP:
ESTIMATED_TOTAL_PRICE:
G_PREPARED_BY:
H_DATE: 06 June 19
1_APPROVED_BY:
J_DATE: 06 June 19
Page: 1
reg38t: 2
A_CONTRACT_LINE_ITEM_NO: 0001
B_EXHIBIT: NA
TDP:
TM:
OTHER: NA
DSYSTEMITEM: PHAP Case Files
E_CONTRACTPR_NO: F5BFDP9155AW01
FCONTRACTOR: Goldbelt Glacier Health Services
of_pages: 1
Reset:
	2019-06-06T11:20:41-0400
HARRIS.DANTHONY.TEON.1286867770

	2019-06-06T15:02:01-0400
HILL.MARY.Z.1068819560

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