B01_Attachment_7_DHA_Form_41.docx

DEFENSE HEALTH AGENCY (DHA) SUBCONTRACTING PLAN REVIEW CHECKLIST

Solicitation Number/Contract:

Mod Number to Contract:

Total Amount of Contract:

Date:

Description of Product/Service:

Type of Plan (Check One) (FAR 19.701 and DFARS 219.702) |_| Individual |_| Master Plan |_| Commercial Product Plan |_| Comprehensive Plan Contract Specialist (CS) Name: Office: Phone:

Contracting Officer (CO) Name: Office: Phone:

Address:

SMALL BUSINESS ADMINISTRATION PROCUREMENT CENTER REPRESENTATIVE (SBA PCR)

ACCEPTABLE = A

UNACCEPTABLE = U

Note: See Page 3 for Percentages and Dollars Per Year

(c) Small Disadvantaged Business (SDB) Concerns (includes Historically Black Colleges and Universities (HBCU), and Minority Institutions (MI), Alaska Native Corporations and Indian Tribes)

11. SPECIAL CIRCUMSTANCES:

a. If the contract contains options or is a multiyear contract, does the plan contain separate statements and goals for the basic contract and each option? YES |_| NO |_| N/A |_|

b. If this is a master plan:

(1) Has the master plan has been approved? YES |_| NO |_| N/A |_|

(2) Has the offeror provided copies of the master plan and evidence of its approval? YES |_| NO |_|

c. If this is a commercial plan, has the contractor and CO complied with the requirements of FAR 19.704(d) for the submission, negotiation, and approval of commercial subcontracting plans? YES |_| NO |_| N/A |_|

d. For contract modifications, does this plan provide revised Small Business subcontracting goals to the basic contract?

YES |_| NO |_| N/A |_|

12. CONTRACT SPECIALIST (if assigned to review) - REVIEW AND REMARKS (IF NONE, SO STATE):

CONTRACT SPECIALIST NAME TELEPHONE ( ) -

SIGNATURE __________________________________________________ DATE

13. CONTRACTING OFFICER - REVIEW AND REMARKS (IF NONE, SO STATE):

In accordance with FAR 19.704, FAR 19.705-4, and DFARS 219.705-4, I have reviewed this subcontracting plan for adequacy, and all required information, goals, and assurances are included, except as noted above.

CONTRACT OFFICER NAME TELEPHONE ( ) -

SIGNATURE __________________________________________________ DATE

14. DIRECTOR, DHA OFFICE OF SMALL BUSINESS PROGRAMS - REVIEW AND REMARKS (IF NONE, SO STATE):

NAME TELEPHONE ( ) -

SIGNATURE __________________________________________ DATE

15. SMALL BUSINESS ADMINISTRATION PROCUREMENT CENTER REPRESENTATIVE - REVIEW AND REMARKS (IF NONE, SO STATE):

NAME TELEPHONE ( ) -

SIGNATURE __________________________________________ DATE

16. LEVEL ABOVE THE CONTRACTING OFFICER - APPROVAL:

In accordance with DFARS 219.705-4(d),a small business goal of less than five percent is established in the plan, then the plan must be approved at a level above the CO and placed in the contract file.

NAME TELEPHONE ( ) -

SIGNATURE ______________________________________________ DATE

[Ensure following statement is added at top and bottom of each page upon finalizing document:

PROCUREMENT SENSITIVE INFORMATION]

[Ensure the following statement is added at top and bottom of each page upon finalizing document:

PROCUREMENT SENSITIVE INFORMATION]

DHA SUBCONTRACTING PLAN REVIEW CHECKLIST

(Continued)

[Ensure the following statement is added at top and bottom of each page upon finalizing document:

PROCUREMENT SENSITIVE INFORMATION]

DHA Form 41, DATE: June 2014 [Ensure the following statement is added at top and bottom of each page upon finalizing document:

PROCUREMENT SENSITIVE INFORMATION]

Goal (Note: DHA will use DoD SB Subcontracting Goals)

1. SB (include SDB, WOSB, HBCU/MI, HUBZone, Alaska Native Corporations and Indian Tribes) (Dollars and Percent of 3.)

2. Large Business (Dollars and Percent of 3.)

3. Total (Sum of 1. and 2.)

4. SDB (include HBCU/MI, Alaska Native Corporations and Indian Tribes) (Dollars and Percent of 3.)

5. WOSB

(Dollars and Percent of 3.)

6. HBCU/MI

(Dollars and Percent of 3.)

7. HUBZone (Dollars and Percent of 3.)

8. VOSB

(Dollars and Percent of 3.)

9. SDVOSB

(Dollars and Percent of 3.)