ATTACHMENT_3_TECHNICAL_CAPABILITY_VALIDATION_SHEET.pdf

ATTACHMENT 3

TECHNICAL CAPABILITY VALIDATION SHEET

This form is used for the purposes of a Defense Health Agency (DHA) Medical Q-coded Services (MQS) solicitation. The data provided on this sheet is for informational purposes only. The data is designed to capture the medical services previously performed by the Offeror listed below. By signing this form, the customer Point of Contact (POC) confirms that the information is correct. Note: This document is not a past performance evaluation and does not capture the quality of the work completed. This document only attests that the work was performed. If you have any questions, please contact Jennifer Felt at (210) 221-6231.

Offeror: Shall complete Sections 1 through 3 and send to agency/organization primary customer point of contact (POC) for review and signature in Section 4. Use one form for a single customer POC if using more than one task order to support multiple claimed items on ID/IQ contracts. Note: Do no consolidate multiple task orders to claim a higher point value on a single row in the Self Scoring Technical Capability Worksheet. If you have problems getting a signed validation sheet from the Government, please contact Jennifer Felt at (210) 221-6231.

Primary Customer POC: Review and sign the form if the information is accurate. Send the signed form to the originator of the request NLT (Offeror will enter date). If you have any questions about sending this form to the Offeror, please contact Jennifer Felt at DHA (210) 221-6231.

Offeror Name:

Section 1: Contract Information Contract Number:

Name of prime Contractor:

(if different than Offeror name above)

Name of Contractor Performing the Work:

(if different than prime Contractor)

Contract Type (fixed price; cost reimbursement; incentive; IDIQ):

Contract Arrangement (personal services/non-personal services):

Total Contract Value (including all options):

Section 2: Agency/Organization Agency/Organization Name:

Agency/Organization Address:

Name of Point of Contact:

Telephone Number:

Email Address:

Section 3: Performance Specifics (Add rows and number sequentially, if needed)

(Do not use more than one row for each item claimed on the Self Scoring Technical Capability Worksheet. Circle row associated with item claimed)

Item # Task Order # (if applicable)

Labor Category # of FTEs

Location (State where services were provided)

Period of Performance

(Must be from 1 Jan 12 through 30 Sep 16)

Clinical Setting (See explanations in Attachment 5)

Task Order Value

Section 4: Agency/Organization Signature

(If any row in Section 3 is not correct, line through the incorrect row before signing this form) I confirm that the information listed on this sheet is true and accurate:

Signed (Agency/Organization Representative):

Printed Name ________________, Telephone ___________________, E-mail ___________________ Note: Offeror shall use this sheet as listed in 52.212-1, Technical Capability Supporting Documentation.