SF_18_HSHQDC-15-Q-00270.pdf

HSHQDC-15-Q-00270

1. REQUEST NO.

5a. ISSUED BY

NAME

a. NAME

c. STREET ADDRESS

d. CITY

10. PLEASE FURNISH QUOTATIONS TO

THE ISSUING OFFICE IN BLOCK 5a ON

OR BEFORE CLOSE OF BUSINESS (Date)

2. DATE ISSUED 3. REQUISITION/PURCHASE REQUEST NO. 4. CERT. FOR NAT. DEF.

UNDER BDSA REG. 2

AND/OR DMS REG.1

RATING

6. DELIVERY BY (Date)

7. DELIVERY

9. DESTINATION

a. NAME OF CONSIGNEE

b. STREET ADDRESS

PAGE OF PAGES

5b. FOR INFORMATION CALL: (No collect calls)

TELEPHONE NUMBER

AREA CODE NUMBER

8. TO:

b. COMPANY

e. STATE f. ZIP CODE

c. CITY

d. STATE e. ZIP CODE

IMPORTANT: This is a request for information, and quotations furnished are not offers. If you are unable to quote, please so indicate on this form and return it to the address in Block 5a. This request does not commit the Government to pay any costs incurred in the preparation of the submission of this quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or certifications attached to this Request for Quotations must be completed by the quoter.

11. SCHEDULE (Include applicable Federal, State and local taxes)

THIS RFQ

REQUEST FOR QUOTATION

(THIS IS NOT AN ORDER)

IS IS NOT A SMALL BUSINESS SET ASIDEX

07/17/2015

1 3

Office of Procurement Operations Dept. Operations Acquisition Div.

245 Murray Lane, SW, #0115

U.S. Dept. of Homeland Security

Washington DC 20528-0115

202 447-5568Ni'eema Bath

07/31/2015 1000 ES

FOB DESTINATION

OTHER

(See Schedule)X

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

This is a Request for Quotation for Medical Subject Matter Expert Support Services in support of the Department of Homeland Security (DHS), Office for Civil Rights and Civil Liberties

(CRCL).

*Note: DHS intends to acquire these services by awarding two (2) multiple contracts. However, DHS reserves the right to increase or decrease the number of awardees based upon the results of the evaluation. Estimated hours will be among the two awardees equally. The total combined amount of hours will not exceed 302 hours, per year.

DO/DPAS Rating: NONE Period of Performance: 09/09/2015 to 09/08/2020

Continued ...

12. DISCOUNT FOR PROMPT PAYMENT

a. 10 CALENDAR DAYS (%) b. 20 CALENDAR DAYS (%) c. 30 CALENDAR DAYS (%) d. CALENDAR DAYS

NUMBER PERCENTAGE

NOTE: Additional provisions and representations

13. NAME AND ADDRESS OF QUOTER

b. STREET ADDRESS

c. COUNTY

d. CITY e. STATE f. ZIP CODE

14. SIGNATURE OF PERSON AUTHORIZED TO

SIGN QUOTATION

16. SIGNER

a. NAME (Type or print)

c. TITLE (Type or print)

a. NAME OF QUOTER

AREA CODE

NUMBER

15. DATE OF QUOTATION

b. TELEPHONE are are not attached

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition not usable

STANDARD FORM 18 (REV. 6-95)

Prescribed by GSA - FAR (48 CFR) 53.215-1(a)

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

HSHQDC-15-Q-00270

0001 (Base Period) Subject Matter Expert - 302 HR

Medical/Nursing

FOB: Destination

Period of Performance: 09/09/2015 to 09/08/2016

0002 (Base Period) Travel

Not-To-Exceed $10,000.00

FOB: Destination

Period of Performance: 09/09/2015 to 09/08/2016

1001 (Option Period 1) Subject Matter Expert - 302 HR

Medical/Nursing

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2016 to 09/08/2017

1002 (Option Period 1) Travel

Not-To-Exceed $10,240.00

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2016 to 09/08/2017

2001 (Option Period 2) Subject Matter Expert - 302 HR

Medical/Nursing

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2017 to 09/08/2018

2002 (Option Period 2) Travel

Not-To-Exceed $10,480.00

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2017 to 09/08/2018

3001 (Option Period 3) Subject Matter Expert - 302 HR

Medical/Nursing

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2018 to 09/08/2019

3002 (Option Period 3) Travel

Not-To-Exceed $10,720.00

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2018 to 09/08/2019

Continued ...

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

HSHQDC-15-Q-00270

4001 (Option Period 4) Subject Matter Expert - 302 HR

Medical/Nursing

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2019 to 09/08/2020

4002 (Option Period 4) Travel

Not-To-Exceed $11,000.00

(Option Line Item)

FOB: Destination

Period of Performance: 09/09/2019 to 09/08/2020

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)