M040_Clinical_Support_Agreement_(CSA)_Report_Rev_06.19.15.pdf

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

Frequency: Monthly Reporting Period Start Date: Start of service delivery Due Date: 60 calendar days after end of reporting period

SUBSEQUENT SUBMISSION: SAME AS FIRST SUBMISSION

PHI/PII: No FILE FORMAT: Microsoft Excel

CONTENT DETAILS:

The contractor shall submit a monthly report detailing all Clinical Support Agreement (CSA) activities which occurred during the previous month. A copy shall also be provided to the appropriate Military Treatment Facility (MTF) Manager. The contractor shall provide a separate report for each MTF and a summary.

This report shall be multi-part and shall include the following divisions:

CSA Requirements received during the previous month and the status of each;

CSA executed contract actions received from the Procuring Contracting Officer (PCO) during the previous month and the status of each;

A status for each CSA Requirement received during a prior reporting period until one month following the receipt of a CSA executed contract action; and A status for each CSA executed contract action received during a prior reporting period.

For all active CSA executed contract actions issued by the PCO, the contractor shall also provide the following:

The number of CSA personnel by executed contract action and by specialty or personnel type working in each MTF;

The number of hours worked by CSA personnel, by executed contract action, and by specialty or personnel type for each MTF;

Provide CSA personnel identifiers; Name, NPI, EDIPN, dates of employment, and place of employment The total cost to the government and a breakdown of salaries, compensation, and other expenses paid by the contractor in support of the services provided for each executed contract action Total reimbursement expected from the government for services not rendered through each executed contract action during the reporting period.