MRI Services.pdf Post.pdf

SEE ADDENDUMIS CHECKED

CODE 18a. PAYMENT WILL BE MADE BY

CODE

FACILITYCODE

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

OFFEROR

Belcourt ND 58316 PO Box 160 1300 Hospital Road Belcourt PHS Indian Hospital

CODE 16. ADMINISTERED BYCODE

X

X

X

621512

SIZE STANDARD:

% FOR:SET ASIDE:UNRESTRICTED OR163

RFPIFB

10. THIS ACQUISITION ISCODE

RFQ

14. METHOD OF SOLICITATION

13b. RATING

NAICS:

SMALL BUSINESS

03/29/2022

701-477-8419PHYLLIS GOURNEAU

(No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIME

04/14/2022 1200 CT

b. TELEPHONE NUMBERa. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

75H70622Q00006

5. SOLICITATION NUMBER

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF

1 8 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

TELEPHONE NO.

17a. CONTRACTOR/

15. DELIVER TO

Belcourt ND 58316 P.O. Box 160 1300 Hospital Road

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

$16.50

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

ISSUE DATE

DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

11.

SEE SCHEDULEX

12. DISCOUNT TERMS

THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

8(A)

Belcourt PHS Indian Hospital

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

The Quentin N Burdick Memorial Healthcare Facility (QNBMHF) in Belcourt, North Dakota is requesting responses to this Request for Quote (RFQ) to provide Mobile MRI Services. QNBMHF intends to award an Indefinite Delivery - Indefinite Quantity (IDIQ) contract. The RFQ is issued as a small business set aside, and the associated NAICS Code is NAICS Code 621512 - Diagnostic Imaging Centers Size Standard $16,500.00

(Use Reverse and/or Attach Additional Sheets as Necessary)

HEREIN, IS ACCEPTED AS TO ITEMS:

DATED

CRAIG J. WELLS

. YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ARE

ARE

31c. DATE SIGNED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

OFFER

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

ARE NOT ATTACHED.

ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30b. NAME AND TITLE OF SIGNER (Type or print)

30a. SIGNATURE OF OFFEROR/CONTRACTOR

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT:

REF.

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

This ID/IQ contract does not obligate any funds.

Funds will be obligate on an individual basis as

Task Orders and will be issued electronically sent via e-mail. For details please refer to the attached clauses FAR 52.216-18 Ordering, FAR

52.216-19 Order Limitations and FAR 52.216-22

Indefinite Quantity. The Unit Price is an all-inclusive cost. All inclusive cost is defined to include travel, lodging, per diem, fringe benefits, i.e., life insurance, social security, federal, state, and local taxes, plus all other costs pertinent to the performance of this IDIQ Contract.

SEE Attached Bid Schedule to submit pricing

Period of Performance will be Award date for one year and four one year options.

FAR 52.212-1 - Instructions to Offerors -

Commercial Items (November 2021): Quotes shall be submitted on company letterhead stationary, signed and dated and it shall include:

1. Solicitation number 75H70622Q00006

2. Closing date of April 14, 2022 at 1200 (Noon)CST.

3. Name, address, telephone number of the offeror and email address of the contact person.

Continued ...

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

8 2 of

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 8

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements in the solicitation. This may include documents, if necessary;

5. Remit to" address, if different than mailing address;

6. A completed copy of the representations and certifications at FAR 52.212-3 see FAR

52.212-3(b) for those representations and certifications that the offeror shall complete electronically.

7. Acknowledgment of Solicitation Amendments (if any issued)

8. Resume stating ability to meet qualifications and the requirements of the statement of work for any and all candidate presented with the RFQ.

9. Past Performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (to include contract numbers, points of contact with telephone number and other pertinent information)

10. A statement specifying the extent of agreement with all terms, conditions and provisions included in the solicitations.

Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded

In addition, Contractor shall provide the following in order to be considered technically acceptable.

1. Complete and sign Agreement of Child Care

Position of Provisional Authorization.

2. Complete and sign Declaration for Federal

Employment Option Form 306

3. Complete and sign Addendum to Declaration for

Federal Employment Option Form 306

4. Complete and sign Licensure Requirement Form.

5. Copy of Malpractice insurance coverage.

6. Shall meet the Professional Qualifications

Criteria of the Statement of Work

7. Copy of Board Certifications

8. Copy of active, current full and unrestricted license to practice.

9. Copy of Diplomas/Specialty Certification

Continued ...

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

Sponsored by GSA

FAR (48 CFR) 53.110

4 8

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006

10. Copies of Continue Education

11. Current CV/resume

12. Name and phone number of three (3) current professional references

13. Copy of recent Health Examination

BASIS FOR AWARD

Quoters are advised that the Government will award a contract resulting from this solicitation to the lowest responsible offeror whose offer conforming to the solicitation will me most advantageous to the Government, price and other factors considered. Award shall be made to the

Lowest Price Technically Acceptable Offer. The following factors shall be used to evaluate offers.

1. Price

FAR 52.212-3 - Offeror Representations

Certifications - Commercial Items (Nov 2021)

- See attachment for full text and instruction for completion. An offeror shall complete only paragraph (b) of this provision if the offeror has completed the annual representations and certifications electronically via http://www.sam.gov. If an offeror has completed the annual representations and certifications electronically at the System for Award Management

(SAM) website, the offeror shall complete only paragraph (c) through (o) of this provision.

FAR 52.212-4 - Contract Terms and Conditions -

Commercial Items (November 2021) - See attachment; in by reference

FAR 52.212-5 - Contract Terms & Condition's

Required to Implement Statutes or Executive

Orders - Commercial Items (January 2022) - See attachment for full text.

Attached are the Federal Acquisition Regulations

(FAR) and the Health & Human Services Acquisition

Regulation (HHSAR) clauses that are applicable including the in the attachment

Offers will be accepted electronically, Submit via e-mail to the following:

Continued ...

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

5 8

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006

Quentin N Burdick Memorial Healthcare Facility -

Indian Health Service

Phyllis Gourneau, Contract Specialist

PO Box 160

Belcourt, North Dakota 58316 e-mail: Phyllis.gourneau@ihs.gov

Phone: (701)477-8419

Contractor will need a DUNS number, TIN number and be registered with www.SAM.gov

Indian Health Service, requires Contractors to complete the Mandatory Annual Training, Protecting Children from Sexual Abuse by Health

Care Providers. Therefore, please forward this email to all health care contractors that are and will be working at any one of our IHS facilities.

Here's the Link for Contractors to access the site;

https://www.ihs.gov/sexualabuseprevention/training

When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and

Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

SECURITY CLEARANCE

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.).

Before starting work requiring routine access to

I.H.S. facilities or systems each person must complete a FBI National Criminal History Check

(Fingerprint Check) adjudicated by an I.H.S.

employee using the Office of Personnel Management

Personnel Investigations Processing System.

Contractors shall allow five business days for

I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of

I.H.S. sites with electronic fingerprint capability is available from the Contracting

Officer.

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of

Inspector General List of Excluded

Continued ...

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

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006

Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the

Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access.

If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with

IPAs or MOAs to tribal organizations please, click here IHS Sexual Abuse Prevention website.

When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and

Time to their Supervisor, COR, and Kimmen LeBeau, e-mail:

In the event the Contractor is unable to fulfill the task order requirements for whatever reason;

the government reserves the right to fulfill its need outside of this contract. A written confirmation from the contractor indicating the inability to fulfill the task order is

Continued ...

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

7 8

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006 immediately required. The quantity of hours ordered on the unfilled task order will be applied to the minimum quantity. The governments right to fulfill its need outside this contract(s) does not waive its right to the issuance of a cure notice nor does it waive its right to terminate for default.

Period of Performance: 05/01/2022 to 04/30/2027

SEE BID SCHEDULE TO SUBMITT PRICING

Period of Performance: 05/01/2022 to 04/30/2027

INVOICE SUBMISSION AND PAYMENT

The Contractor shall submit a signed and approved invoice to request payment on at least a monthly basis.

(a) The Contractor shall submit an original invoice to:

Attn: Accounts Payable

Great Plains Area Indian Health Service

Division of Financial Management

115 4th Avenue Southeast

Room 309 Federal Building

Aberdeen, South Dakota 57401

(b) The Contractor shall include the following information on each invoice in accordance with the Prompt Payment Act (5 CFR Part 1315.9(b)):

1. Contractor's name;

2. Invoice number and date;

3. Entire award number or other authorization number for delivery of goods or services;

4. Description (including dates of service), price, and quantity of goods and services rendered;

5. Shipping and payment terms;

6. DUNS number and Taxpayer Identifying Number

(TIN); and

7. Contact name (where practicable), title and telephone number.

Payment shall be made by the Great Plains Area

Financial Management Branch, Room 309 Federal

Building, Aberdeen, South Dakota 57401.

Continued ...

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

8 8

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

75H70622Q00006

The Government reserves the right to accept or reject services if the level or work is unsatisfactory.

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

RFQ 75H70622Q0006 -Mobile MRI Services - RFQ Quentin N Burdick Memorial Healthcare

Facility in Belcourt, North Dakota

Bid Schedule - QNBMHF in Belcourt, ND - Please Submit Pricing on this Bid Schedule

IHS Service Unit Description Quantity Un.It of Issue Unit Price

1 Belcourt I.H.S Service Unit Mobile MRI Services

Price per day ____ _ X 48 Days ___________ _

POP 05/01/2022 to 04/30/2023-Base Yr.

2. Belcourt I.H.S Service Unit Mobile MRI Services

Price per day _____ X 48 Days ___________

_ POP 05/01/2023 to 04/30/2024 -Option Yr. One (1)

3. Belcourt I.H.S Service Unit Mobile MRI Services

Price per day _____ X 48 Days ___________ _

POP 05/01/2024 to 04/30/2025 -Option Yr. Two (2)

14. Belcourt I.H.S Service Unit Mobile MRI Services

Price per day _____ X 48 Days ___________ _

POP 05/01/2025 to 04/30/2026 -Option Yr. Three (3)

5. Belcourt I.H.S Service Unit Mobile MRI Services

Price per day _____ X 48 Days ___________

_ POP 05/01/2026 to 04/30/2027 -Option Yr. Four (4)

Total Cost Base Plus Four Option Years .. =

Total Cost

STATEMENT OF WORK

MOBILE MRI

QUENTIN BURDICK MEMORIAL HEALTHCARE FACILITY

Belcourt, North Dakota 58316

Purpose of the Contract

To provide Mobile MRI services for the QUENTIN BURDICK MEMORIAL

HEALTHCARE FACILITY in Belcourt, North Dakota. Mobile MRI Technologist must be ARRT certified provide proof of credentials.

The mission of the Quentin N. Burdick Memorial Health Care Facility in Belcourt, North

Dakota is to provide the best possible Health Care services to the Native American population on the Turtle Mountain Indian Reservation. The 27-bed facility is also known as the Belcourt Indian Health Service or the QNBHF. Contract is a Base plus 4 year option

To meet the mission of the Quentin N. Burdick Memorial Health Care Facility it will require contractor support to assist the Indian Health Service Hospital with Mobile MRI services in, The Great Plains area.

Contract resulting from this solicitation shall:

a.) Be a fixed-price non-personal health care service contract under which the

Contractor is an independent contractor.

b.) Allow the Government to evaluate the quality of professional and administrative services provided. Must come on Tuesday’s 4 times a month excluding federal holidays; be able to do up to 12/14 patients a day, not scans. Will provide gadolinium at no extra charge.

c.) Requires the contractor to provide quality exams with no returns. The contractor will be reviewed monthly on the quality of exams submitted for interpretation by the radiology supervisor or the project officer.

Government Furnished Property, Facilities and Services

The government will provide any property, power, facilities, forms, supplies, and phone lines or physician’s services if needed, ex: contrast reaction, during the term of this contract.

Contractor Furnished Property:

The Contractor will provide the necessary equipment to have the capabilities to do mobile MRI’s and provide gadolinium at no extra charge. The mobile unit shall be parked in the south parking lot of the Belcourt PHS IHS facility. The Contractors viewing equipment shall be DICOM compliant and able transmit images to a GE Centricity IW

PACS. Contractor shall be responsible for any at its own cost maintenance and operation of equipment. Furthermore, the contractor shall make all preventive maintenance repairs and unscheduled repairs in a timely manner in order to minimize disruption of services.

Any problems with the equipment will be immediately communicated to the Radiology

Supervisor or Project officer or his/her designee at the Quentin N. Burdick memorial

Health Care Facility. The contractor at its own expense shall provide services for (8) eight hours a day and shall provide a certified technologist to operate mobile equipment.

Statement of Work

The Contractor will be required to provide medical studies and requires the contractor to provide quality images with no returns, as in exams must be labeled correctly; Right- Left contrast or non-contrast. Exams must be complete so the radiologist can make an appropriate diagnostic interpretation. This will be reviewed on a monthly basis by the

Radiology Supervisor/project officer/CD. Must maintain a 90% retake rate or may be subject to contract termination at reviewer’s discretion.

Review Rights:

i. The authorizing Project Officer, IHS Clinical Director, or his/her professional representative shall be entitled to review the Contractor's

MRI mobile unit physicists report to be in compliance with FDA standards and all administrative and clinical records which pertain to IHS beneficiaries covered under this contract.

ii. The Contractor shall provide access to IHS patient medical records for review by the IHS utilization review official and managed care professional or other designated IHS official.

PROJECT OFFICER: The person identified below is hereby designated as the Project

Officer for this contract. The project officer shall be responsible for : (1) Monitoring the

Contractors technical progress, including surveillance and assessment of performance and recommending technical changes; (2) Interpreting the Statement of Work; (3) Technical evaluation as required; (4) Technical inspections and acceptance; and (5) Assisting the

Contractor in the resolution of technical problems encountered during performance of this contract.

Project officer:

Richard Martell/Dr. Paula Bercier MD, CD

QNBHF-Belcourt PHS IHS

1300 Hospital loop

1 Main Street

PO Box 160

Belcourt, ND 58316

Be here to do exams 4 times a month on Tuesday’s for a total of 48 visits, excluding federal holidays.

In the event of a contrast reaction the mobile unit shall implement the RRS. (Rapid

Response System) notifying the E.R. for assistance.

The government reserves the right to accept or reject services if the level of performance is unsatisfactory to I.H.S.

The CMS, ACR, ARRT, FDA standards must be considered and adhered to at all time’s in order to be compliant.

All Medical Record Information generated in the performance of this contract shall remain the property of and subject to the exclusive control of the Indian Health Service

(I.H.S.).

The Contractor is responsible for maintaining Patient Confidentiality and adhering to the

Privacy Act of 1974 and the Health Insurance Portability & Accountability Act (HIPAA) of 1996

Have no contact with children.

Contractor Qualification

The Contractor shall have extensive knowledge in Anatomy, Physiology and Medical

Terminology to allow for accurate studies to be done on patients of the QNBHCF.

In accordance with Federal Acquisition Regulation (FAR) of Part 9, under Contractor

Qualifications a responsible Contractor must,

(a) Have adequate financial resources available to meet the terms of performance as stated in this contract or the ability to obtain them (see 9.104-3 (a).

(b) Be able to comply with the required or proposed delivery or performance schedule, taking into consideration all existing commercial and government business commitments.

(c) Have a satisfactory performance record (see 9.104-3 (b) and Subpart 42.15).

A prospective contractor shall not be determined responsible or non-responsible solely on the basis of a lack of relevant performance history, except as provided in 9.104-2.

(d) Have a satisfactory record of integrity and business ethics.

(e) Have the necessary organization, experience, accounting and operational controls and technical skill or the ability to obtain them (including as appropriate, such elements as production control procedures, property control systems, quality assurance measure, and safety programs applicable to materials to be produced or services to be performed by the prospective contractor or subcontractors). See 9.104-3(a)

(f) Have the necessary production, construction and technical equipment and facilities, or the ability to obtain them (see 9.104-3(a).

(g) Be otherwise qualified and eligible to receive and award under applicable laws and regulations. Certified as an MRI Technologist.

(h) Contractor will be evaluated on a monthly basis to determine if exams meet the standards as described in contract.

0MB Approvell Form No. 0917-0028

Expiration Date: 11/30/2015

Addendum to Declaration for Federal Employment (OF 306) Indian Health Service

Child Care & Indian Child Care Worker Positions

Item 16. Agency Specific Questions

Name:

(Please print)

Social Security Number: ________ _

Job Title in Announcement: __________ Announcement Number: ____ _

Section 23 I of the Crime Control Act of 1990, Public Law IO 1-64 7, requires that employment applications for individuals seeking employment in a position involved with the provision to children under the age of 18 of "child care services," as defined in 42 U.S.C. 13041 (a)(2).

contain a question asking whether the individual has ever been arrested for or charged with a crime involving a child and for the disposition of the arrest or charge. Under 42 U.S.C.

13041(a)(2), the term "child care services" means child protective services (including the investigation of child abuse and neglect reports), social services, health and mental health care, child (day) care, education (whether or not directly involved in teaching), foster care, residential care, recreational or rehabilitative programs, and detention, correctional, or treatment services.

Individuals hired for such positions must undergo a criminal history background check.

Section 408 of the Indian Child Protection and Family Violence Prevention Act, Public Law IO 1-630, contains a related requirement for positions in the Department of Health and Human Services that involve regular contact with or control over Indian children. The agency must ensure that persons hired for these positions have not been found guilty of or pleaded nolo contendere or guilty to certain crimes. The law requires that the agency conduct an investigation of the character of each individual who is being considered for employment in such a position and prescribe in regulations the "minimum standards of character" that must be met in order for an individual to fill such a position. The regulations specify that ·'[t]he minimum standards of character shall be considered met only after the individual has been the subject of a satisfactory background investigation," which includes a criminal history background check. 42 C.F .R. § 136.406.

To assure compliance with the above laws, the following questions are added to the Declaration for Federal Employment:

I. Have you ever been arrested for or charged with a crime involving a child?

YES __ NO __

[{f "YES", provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name and address of the police department or court involved.]

2. Have you ever been found guilty of, or entered a plea of nolo contendere (no contest) or guilty to, any felonious or misdemeanor offense under Federal, State, or tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact or prostitution; or crimes against persons; or offenses committed against children?

YES __ N. __

[{f "YES", provide the date, explanation of the violation, disposition of the arrest or charge, place of occurrence, and the name address of the police department or court involved.]

I cet1ify that (I) my response to these questions is made under penalty of perjury, which is punishable by fine under title 18 of the U.S. Code, or imprisonment of not more than five years, or both; and (2) I have received notice that a criminal check will be conducted. I understand my right to obtain a copy of any criminal history report made available to the Indian Health Service and my right to challenge the accuracy and completeness of any information contained in the report.

Applicant's Signature (sign in ink) Date

Public Burden Statement: In accordance ll'ith Paperll'ork Reduction ii ct [5 CFR I 320.8 (h)O)}, a Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid O:v!B control number. Respondents must he informed (on the reporting instrwnem, in instructions. or in a cover letter) the reasons.for ll'hich the i1?formation ll'ill he collected; the ll'ay the information ll'ill he used to Jitrther the proper pe1formance of the functions r�f the agency;

ll'hether responses to the collection of the information are voluntWJ', required to obtain a benefit (citing authority), or mandatotJ1

(citing authority); and the nature and extent of confidentiality to he provided. if any (citing authority). !'uhlic reporting burden.for this collection of i11formalion is estimated to average 12 minutes per response, induding lime/or reviell'ing instructions, searching existing data sources, gathering and maintaining the nece.1·swJ' data, and completing and reviell'ing the collection information. Send comments regarding the burden estimate or any other aspect of this collection a/information to the J HS P RA leformation Collection Clearance Staff 1230() Twinhrook Parkway, Suite 450, Rockville, MD 20852. Please do not send completed data collection instruments to this adtlress.

Declaration for Federal Employment Form Approved 0MB No. 3206-4182

Instructions -----------------------------------

The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. You may be asked to complete this form at any time during the hiring process. Follow instructions that the agency provides. if you are selected, before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

Ali your answers must be truthful and complete. A false statement on any part of thls declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or Imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11"). Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement

The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually In conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPMIGOVT-1 , General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees;

Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions;

prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically Identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has change d from a self-and-family to a self-only health benefits enrollment;

individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement ----------------------------

Public burden reporting for this collection of information Is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The 0MB number, 3206-0182, is valid. OPM may not collect this Information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management 5 u. s.c. 1302, 3301, 3304, 3328 & 8716

NSN 7540-01·368-7775

Optional Form 306

Revised January 2001 Prevous editions obsolete and unusable

Declaration for Federal Employment

GENERAL INFORMA TJON

Form Approved 0MB No. 3206-4182

1. FULL NAME (First, middle, last)

2. SOCIAL SECURITY NUMBER

3. PLACE OF BIRTH (Include city and state or country) 4. DATE OF BIRTH (MM/0D/YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc) 1.

6. PHONE NUMBERS (Include area codes)

2.

3, 4.

Selective Service Registration

Day •

Night •

If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Are you a male born after December 31, 1959? O YES O NO If "NO" skip 7b and 7c. If "YES" go to 7b.

7b. Have you registered with the Selective Service System? O YES O NO ff "NO'' go to 7c.

7c. If "NO," describe your reason(s) in item #16.

Military Service

8. Have you ever served in the United States Military?

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

If your only active duty was training in the Reserves or National Guard, answer "NO.•

Background Information l"�}t§_t�{i M�il--1

D Honorable

D Honorable

O YES Provide information below

Other, explain

Other, explain

Other, explain

For all questions, provide all additional requested information under Item 16 or on attached sheets. The circumstances of each event you list will be considered. However, In most cases you can still be considered for Federal ;obs.

For questions 9, 10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided In Juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law.

9. During the last 10 years, have you been convicted, been imprisoned, been on probation, or been on YES NO parole? (Includes felonies, fi rearms or explosives violations, misdemeanors, and all other offenses.)

D D If "YES," use item 15 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court Involved.

10. Have you been convicted by a military court-martial in the past 10 years? (If no military service, YES NO

11.

12.

13.

answer "NO." If "YES," use item 16 to provide the date, explanation of the violation, place of D occurrence, and the name and address of the military authority or court involved. 0

Are you now under charges for any violation of law? If "YES," use item 15 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

Are you delinquent on any Federal debt? (Includes dellnquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Govemment, plus defaults of Federally guaranteed or Insured loans such as student and home mortgage loans.) If "YES, "use item 15 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error to repay the debt, YES

YES

YES

NO

NO

NO

U.S. Office of Personnel Management 5 u.s.c. 1302, 3301, 3304, 3328 & 8716

NSN 7540-01-368-7775 Optional Form 306

Previous editions obsolete end unusable

Declaration for Federal Employment Form Approved 0MB No. 3206-4182

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form? YES NO (Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, 15.

father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, 0 D stepson, stepdaughter, stepbrother, stepsister, half brother, and half sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relative works.

Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

Continuation Space I Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authon'zed to ask them).

Certifications I Additional Questions -------------------------

APPLICANT: If you are applying for a position and have not yet been selected, carefully review your answers on this form and any attached sheets. When this form and all attached materials are accurate, read item 17, and complete 17a.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the dale you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions. When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or Its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or Imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order, I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that tor financial or lending institutions, medical Institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted tor such a release at a later date.

17a. Applicant's Signature:

(Sign in ink)

17b. Appointee's Signature:

(Sign In Ink)

Date

Date

Enter Dale of Appointment or Conversion

MM/00/YYYY

18. Appolntee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life Insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? DATE: MMIDDIYYYY

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

18c. If you answered ''YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

U.S. Office of Personnel Management 5 u.s.c. 1302, 3301, 3304, 3328 & 8716

NSN 7540-01-368-7775

YES NO Do Not Know

□ D D YES NO Do Not Know

D D □

Opllonal Form 306

Previous editions obsolete and unusable

AGREEMENT TO A TEMPORARY WAIVER OF CHARACTER

INVESTIGATION (FOR GOVERNMENT EMPLOYEES, CONTRACTORS,

STUDENTS AND VOLUNTEERS)

Per your request, the Northern Plains Region of the Indian Health Service (Aberdeen, Bemidji and Billings Area Offices) has agreed to a temporary waiver of the character investigation for

(Name of employee, volunteer, student, contractor)

This temporary waiver has been agreed to with the understanding that you wilJ continue the process of accomplishing the character investigation in accordance with Public Law I 01-630, Indian Child Protection and Family Violence Prevention Act and Public Law IO 1-64 7, Crime Control Act.

The agreement is in effect until the signed certificate of investigation is received by the HSPD- 12/Security Office. I understand that in accordance with Section 231 of the Crime Control Act of 1990 (P .L. 101-64 7 and P.L. 101-630), that failure to comply with these statues could result in my immediate removal.

Your signature indicates you are taking the responsibility to assure Human Resources and/or the Senior Contracting Officer, and the HSPD-12/Security Office that the above named individual will not have unmonitored contact with Indian children.

I hereby assure that such continuous monitoring will occur when said individual is in contact with Indian Children under the age of 18 years. I am aware, and will assure, that those providing DIRECT SIGHT MONITORING shall at a minimum, have had a successfully completed CNACI.

I certify that the permanent federal employees assigned to provide DIRECT SITE MONITORING has met the requirements of Section 231 of the Crime Control Act of 1990 (P.L. IO 1-630)

SIGNATURE OF INDIVIDUAL RESPONSIBLE

FOR DIRECT SIGHT MONITORING

CHIEF EXCUTIVE OFFICER

DATE

DATE

(PLEASE COMPLETE AND RETURN)

LICENSURE REQUIREMENT

PERSONAL AND NONPERSONAL SERVICES CONTRACTORS SHALL BE SUBJECT TO THE SAME

QUALITY ASSURANCE, CREDENTIALS, LICENSURE, AND OTHER QUALIFICATION STANDARDS

AS THOSE REQUIRED OF !HS PERSONNEL. IN ADDITION, HEAL TH CARE PROVIDERS, OTHER

THAN PROFESSIONALS, MUST BE LICENSED IN A STATE, THE DISTRICT OF COLUMBIA, PUERTO

RICO, OR A TERRITORY OF THE UNITED STATES TO PERFORM THE CONTRACT SERVICES

WITHIN IHS FACILITIES. THE CONTRACTING OFFICER WILL INSERT THE FOLLOWING

CERTIFICATION STATEMENT IN ALL PURCHASE ORDERS AND CONTRACTS FOR

PROFESSIONAL MEDICAL SER VICES:

MY LICENSE TO PRACTICE O HAS O HAS NOT BEEN TERMINATED, SUSPENDED, OR

REVOKED IN ANY STATE, THE DISTRICT OF COLUMBIA, PUERTO RICO, OR A TERRITORY OF

THE U.S ..

I CURRENTLY HOLD AN ACTIVE MEDICAL LICENSE IN THE FOLLOWING STATE(S):

STATE LICENSURE NO. ISSUE DATE

I HAVE AN INACTIVE MEDICAL LICENSE IN THE FOLLOWING STATE(S):

STATE LICENSURE NO. ISSUE DATE

I HEREBY CERTIFY THAT THE PURPOSES OF APPLICATION OF THE FALSE STATEMENTS

PROVISIONS OF THE PROGRAM FRAUD CIVIL REMEDIES ACT OF 1986 (45 CFR 79), THAT TO THE

BEST OF MY KNOWLEDGE, EACH OF THE ABOVE STATEMENTS IS TRUE, ACCURATE, AND

DOES NOT OMIT ANY MATERIAL FACT THAT WOULD RENDER THE STATEMENT FALSE,

FICTITIOUS, FRAUDULENT AS A RESULT OF THE OMISSION.

SIGNATURE OF PRACTITIONER DATE

Appendix_: Business Associate Agreement

I. Authority:

Pursuant to 45 C.F.R. § 164.502(e), the Indian Health Service (IHS), as a covered entity, is required to enter into an agreement with a "business associate," as defined by 45 C.F.R. § 160.103, under which the business associate must agree to appropriately safeguard Protected Health Information (PHI) that it will use and disclose when performing functions, activities or services pursuant to its contract with the IHS. By signing Contract No. ____ (Contract), _______ agrees that it is a Business Associate and will comply with the terms below, in addition to other applicable Contract terms and conditions, and applicable law, relating to the safekeeping, use, and disclosure of PHI. This Appendix comprises the Business Associate Agreement (Agreement).

II. Definitions:

The following terms shall have the same meaning as those terms in 45 C.F.R. Part 160 and Part 164, which are the federal regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended: Breach, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, PHI, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured PHI, and Use.

A. Business Associate. "Business Associate" shall generally have the same meaning as the term "business associate" at 45 C.F.R. § 160.103, and in reference to the party to this Agreement shall mean _____ _

B. Covered Entity. "Covered Entity" shall generally have the same meaning as the term "covered entity" at 45 C.F.R. § 160.103, and in reference to the party to this Agreement, shall mean the IHS.

C. HIPAA Rules. "HIPAA Rules" shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 C.F.R. Part 160 and Part 164, D. Master Patient Index (MPI). The "Master Patient Index" or "MPI" is composed of a unique list of patients and a current list of medical centers where each patient has been seen. This enables the sharing of patient data between operationally and regionally diverse systems. Each record ( or index entry) on the MPI contains a small amount of patient data used to identify individual entries.

The mission of the MPI is to uniquely identify a patient and to "link" that patient's data throughout the IHS facilities using the Integration Control Number (ICN). The MPI is the authoritative source of a patient's ICN, the enterprise-wide identifier for IHS facilities and the key to accessing a patient's record. The accuracy of patient information and patient identification directly affects clinical, administrative, billing, and interdepartmental processes.

III. _Obligations and Activities of Business Associate:

A. Compliance: Business Associate agrees not use or disclose PHI other than as authorized by the Agreement or as required by law. Business Associate acknowledges that it is directly liable under the HIPAA Rules and subject to civil and, in some cases, criminal penalties for making uses and disclosures of PHI that are not authorized by the Agreement or required by law. Business Associate agrees that it will require all of its agents, employees, subsidiaries, and affiliates, to whom Business Associate provides PHI, or who create or receive PHI on behalf of Business Associate for Covered Entity, to comply with the HIP AA Rules and to enter into written agreements with Business Associate that provide the same restrictions, terms, and conditions as set forth in the Agreement.

B. Subcontractors: In accordance with 45 C.F.R. §§ l 64.502(e)(l )(ii) and 164.308(6)(2), which govern relations with subcontractors, Business Associate agrees to ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of Business Associate agree to the same restrictions, terms, and conditions that apply to Business Associate with respect to such PHI.

C. Safeguarding PHI: Business Associate shall develop and use appropriate procedural, physical, and electronic safeguards to protect against the use or disclosure of PHI in a manner not authorized by this Agreement or required by law. Business Associate will limit any use, disclosure, or request for use or disclosure of PHI to the minimum amount necessary to accomplish the intended purpose of the use, disclosure, or request.

D. Safeguarding Electronic PHI: Business Associate agrees to use appropriate safeguards, as set forth in Subpart C of 45 C.F.R. Part 164 with respect to electronic PHI, to prevent use or disclosure of electronic PHI other than as authorized by this Agreement or required by law.

E. Reporting Use or Disclosures Not Authorized By this Agreement or Required by Law: Business Associate agrees to report to Covered Entity any use or disclosure of PHI not authorized by this Agreement or required by law within thirty (30) days of discovering the use or disclosure, or any security incident of which it becomes aware. In addition, Business Associate shall mitigate, to the extent practicable, any harmful effect that is known to Business Associate of the use, disclosure, or security incident.

F. Reporting of Breach: In accordance with the policy of the Department of Health and Human…