(PQS)- DBC Form 5112-R1_070622.pdf

DBC 5112

Revised 7/6/22

Department of Health Design and Construction Department

PROFESSIONAL QUALIFICATIONS SUPPLEMENT (PQS)

PURPOSE:

The Professional Qualifications Supplement (PQS) Form DBC-5112, as modified by the Department of Health, is to provide information regarding the qualifications of interested firms to perform Architectural/Engineering services on a specific project. The Department of Health, as delegated by the Department of Management Services and in accordance with the requirements of Section 287.055, F.S., “Consultants’ Competitive Negotiation Act,” will administer the project.

INSTRUCTIONS:

Type accurately; instruction numbers correspond to the numbers on the form; additional pages corresponding to any of the numbered items may be attached.

For the APPLICANT ONLY: attach a copy of the current Florida Department of Professional Regulation License(s) with the appropriate Board(s) for each of the license numbers listed in Number 3.

1. Complete the project number and name as it appears in the Public Announcement for

Professional Services advertised in the Florida Administrative Weekly.

2. Provide the complete Firm Name of the applicant as it appears on the Corporate Seal (if your firm is incorporated), the address and the telephone number of your office. If your firm has two or more office locations, then list the address of the office from which the project(s) will be managed throughout the design and construction phases.

3. For the APPLICANT and the PROPOSED CONSULTANTS, place an X by the service(s) to be provided on the project. Enter the firm's appropriate Department of Professional Regulation license number.* If the firm is a corporation, enter the Florida Corporate Charter Number as issued by the Division of Corporations, Department of State.

* Use the license number in accordance with the name of the firm as presented on the firm's letterhead. Use individual license numbers only when applicable.

4. List, for the APPLICANT firm only, each project currently under contract including contracts as a consultant to another firm. For projects on hold for twelve (12) months or longer, enter the amount of fees remaining (unearned) in the Fees on Hold column. Attach a letter from the owner stating how long the project has been on hold and how much longer it is expected to remain on hold. For all of the other projects, enter the fees (unearned) in the Fees Remaining column. Fees for additional services are to be included.

5. Do not include fees to consultants. Projects shown as “On Hold,” but for which a letter from the owner is not submitted, will be added to the Fees Remaining column. Divide the sum of these fees by the number of licensed personnel, graduate design professionals, lead draftsmen, specification writers and designers, but do not include draftsmen and CADD operators in the number of technical staff.

Department of Health

5a. For the APPLICANT: list all active Department of Health and Department of Management

Services commissions for ALL offices. Indicate total commissions on contract(s) executed for the periods noted. If none, indicate zero.

5b. Indicate the total number of Florida licensed personnel employed by your firm (this data is to be entered whether or not you have or have had contracts with DMS). Indicate the fee per person (licensed personnel) by dividing the total Fee Considered in 5a. by the number of licensed personnel. If 5a is zero, enter zero.

6. List projects comparable to this specific project and related experience accomplished by the applicant. Indicate name of project, completion date, its location, construction cost and phase of project at this time, if applicable.

7. Designate the proposed project team key personnel for the applicant and consultants. For each individual listed, show their discipline(s) of licensure/training and their residence.

8. Sign and date the form; type the name and title of the individual signing.

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Department of Health

1. PROJECT NUMBER: 20221000

PROJECT NAME: North Region Continuing Contract for AE Services

NAME OF APPLICANT FIRM (AS SHOWN ON CORPORATE SEAL):

ADDRESS OF PROPOSED OFFICE IN CHARGE:

PHONE No.

2. INDICATE SERVICES TO BE PROVIDED ON THE PROJECT:

APPLICANT (Prime) PROPOSED CONSULTANTS

Service(s) Offered

Fl State License No.

Corporate Charter No.

Name of Consultant

Fl State License No.

Corporate Charter No.

Architectural

Landscape Architecture

Civil Engineering

Electrical

Mechanical

Structural

Land Surveying

Other

Other

Department of Health

3. WORKLOAD FOR APPLICANT FIRM ONLY:

Define each project the APPLICANT is handling as of the deadline for the submittal on this project (exclude portions of fees paid to consultants). Specify number of all principals and technical staff in the firm (excluding staff drafting/CADD operator personnel and Consultants).

FEES FOR CURRENT PROJECTS

Project Name, Location, and Client Fees on Hold Fees Remaining

TOTALS:

TOTAL ON HOLD + REMAINING: $

Total Persons (Principals & Technical Staff): $

Total divided by Total Persons: $

Department of Health

5a. Fees of Applicant (excluding portions of fees paid to consultants) under contract(s) with the Department of Health listed according to date of agreements for the periods noted as of July 1 of the current year.

Period

Total Fee

Factor

Portion of Fee Considered

(1) From July 1 to current date $ x 1.0 $

(2) First year past (July 1 - June 30) date x 0.8

(3) Second year past (July 1 - June 30) date x 0.6

(4) Third year past (July 1 - June 30) date x 0.4

(5) Fourth year past (July 1 - June 30) date x 0.2

Total Fee Considered: $

5b. Number of Florida licensed personnel Fee Per Person: $

Department of Health

6. SPECIFIC RELATED EXPERIENCE (projects of comparable type, size and complexity):

Project Name and Client

Completion

Date

Location

Construction Cost

Phase

Department of Health

7. KEY PERSONNEL OF PROPOSED TEAM TO BE USED ON THE PROJECT:

NAME DISCIPLINE OF

LICENSE/TRAINING

CITY OF RESIDENCE

Principal(s)-in-charge:

Professional/Technical Staff:

CONSULTANT(S) or in-house staff Principal(s)-in-charge:

Professional/Technical Staff:

8.

Signature

Type Name and Title of Signer Date