IHS IEE Representation Form_Jan 2022_508 Compliant.pdf
PDF 805 KB Posted
- Attached to
- Pediatric Nurse Practitioner Services Federal contract opportunity
- Solicitation number
- IHS1492154
About this file
This document is an Indian Health Service (IHS) solicitation for a non-personal services contract to provide Pediatric Nurse Practitioner healthcare providers to the Pinon Health Center, Navajo Area IHS. The solicitation is a Buy Indian set-aside, meaning only offers from Buy Indian small businesses will be accepted. The period of performance is for 12 months with three 3-month option periods. The IHS is requesting proposals that include pricing, candidate profiles, experience, and past performance. The evaluation will consider best value, with the most important factors being the qualifications and experience of the proposed providers. Offerors must submit the required IHS Indian Economic Enterprise Representation Form. The selected contractor will be responsible for providing all-inclusive rates, travel, housing, and other costs associated with the services. Pre-security and fingerprinting clearance are required prior to the start of the contract.
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| File | Type | Posted |
|---|---|---|
| 52.212-3 Offeror Representations and Certifications—Commercial Products and Commercial Services (Feb 2024).pdf | ||
| Pricing Schedule_PNP.pdf | ||
| PWS - PHC-24-0610-PEDS_NP.pdf | ||
| Wage Determination No. 2015-5477.pdf |
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Text version
DEPARTMENT OF HEALTH & HUMAN SERVICES
Indian Health Service
Office of Management Services Division of Acquisition Policy (DAP)
5600 Fishers Lane Rockville, MD 20857
INDIAN HEALTH SERVICE
BUY INDIAN ACT
INDIAN ECONOMIC ENTERPRISE
REPRESENTATION FORM
SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________
PROJECT TITLE: ________________________________________________________
DATE: ___________________________________________________________________
In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.
The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:
(1) At the time an offer is made in response to this solicitation;
(2) At the time of contract award; and
(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.
Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).
Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.
False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.
REPRESENTATION
The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.
Name of the 51% owner of IEE Firm
Certifying Signature
Print Name
Name of Federally Recognized Tribal Entity
Business Name
Unique Entity ID (UEI)
| DATE: |
| DUNSnumber: |
| BusinessName: |
| NameOfTribalEntity: |
| OwnerName: |
| PrintName: |
| SOLICITATION_NUMBER: |
| PROJECT_TITLE: |
| DoesNot: 0 |
| Does: Off |
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