RFQ-21-100-OB-GYN.pdf

A. This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Federal Acquisition Regulation (FAR) Subpart 12.6, as supplemented with additional information included in this notice, FAR Part 12, Acquisition of Commercial Items (Title VIII of the Federal Acquisition Streamlining Act of 1994) (Public Law 103-355) & FAR 37.4, Non-Personal Health Care Services Contract (10 U.S.C. 2304 and 41 U.S.C 253). This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued.

B. The Great Plains Area Indian Health Service (IHS) intends to award a Firm Fixed-Price, Non-Personal Healthcare Service, Commercial Item, Indefinite Delivery/Indefinite Quantity, Contract in response to Request for Quote (RFQ) RFQ-21-100.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2021-05/03-10-2021.

D. This RFQ is an Unrestricted solicitation and the associated NAICS Code is 621111, which has a small business standard of

$12.0.

E. The quoted unit pricing must be “all inclusive” (to include but not be limited to travel, lodging, per diem, fringe benefits, federal, state and local taxes) plus all other costs pertinent to the performance of this contract. Utilize your most competitive and reasonable rates.

Complete the attached Price Schedule.

1. Base Year: July 1, 2021 through June 30, 2022, 192 Hours x $_________/Hour, totaling $__________.

2. Option Year One (1): July 1, 2022 through June 30, 2023, 192 Hours x $_________/Hour, totaling $__________.

3. Option Year Two (2): July 1, 2023 through June 30, 2024, 192 Hours x $_________/Hour, totaling $__________.

4. Option Year Three (3): July 1, 2024 through June 30, 2025, 192 Hours x $_________/Hour, totaling $__________.

5. Option Year Four (4): July 1, 2025 through June 30, 2026, 192 Hours x $_________/Hour, totaling $__________.

F. Provide OB/GYN Services two days per month, eight hours per day.

G. See attached Statement of Work. Services will be provided for the Fort Thompson Indian Health Service Health Center, Fort

Thompson, South Dakota 57339. The period of performance will be Period of Performance will be July 1, 2021 through June 30, 2022 with Four Option Years.

H. FAR 52.212-1 Instructions to Offerors-Commercial Items (June 2020).

Quotes shall be submitted on company letterhead stationery, signed, dated and it shall include:

1. Solicitation number RFQ-21-100;

2. Closing Date: June 30 at 12:00 pm CST;,

3. Name, address and telephone number of company and email address of contact person;

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

5. Price and any discount;

6. “Remit to” address, if different than mailing address;

7. 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);

8. Acknowledgment of Solicitation Amendments (if any issued);

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 (including contract numbers, points of contact with telephone numbers and other relevant information);

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

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

In addition, Contractors shall provide the following:

• Shall meet the qualifications as stated in the Statement of Work and provide copies of the required documents (if needed).

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

• Complete and sign Child Care Position Provisional Authorization.

• Complete and sign the Declaration for Federal Employment – Optional Form 306.

• Complete and sign Addendum to Declaration for Federal Employment (OF306).

• Complete and sign Licensure Requirement Form.

• Copy of malpractice insurance coverage.

• Copy of a recent Health Examination.

• Copy of Diplomas/Specialty Certifications.

• Current CV/resume.

I. Basis of award is Lowest Price, Technically Acceptable “LPTA” factors determining the successful contractor.

J. FAR 52.212-3 Offer Representations and Certifications-Commercial Items (February 2021). See attachment for full text. The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) website accessed through http://www.acquisition.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (p) of this provision.

K. FAR 52.212-4 Contract Terms and Conditions-Commercial Items (October 2018). Applied to this acquisition and it’s incorporated by reference.

L. FAR 52.212-5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders-Commercial

Items (January 2021). See attachment for full text.

M. Attached are the Federal Acquisition Regulations (FAR) & Health & Human Services Acquisition Regulation (HHSAR) clauses that are applicable including below.

N. Submit quote to:

Great Plains Area Indian Health Service Attn: Wenda Wright, Contract Specialist 115 4th Ave. SE, Room 309 Aberdeen, SD 57401 email wenda.wright@ihs.gov

Questions in regards to this solicitation shall be submitted in writing by either email, fax or mail no later than June 28, 2021, 12:00pm CST.

Contractors will need a DUNS number, TIN number, and be registered with www.sam.gov.

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

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 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 Time and Materials, Labor-Hour or Cost Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. 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.

http://www.acquisition.gov/ mailto:wenda.wright@ihs.gov http://exclusions.oig.hhs.gov/

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 IPA’s or MOA’s 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:

Kimmen.LeBeau@ihs.gov

ACCEPTANCE PERIOD: Your proposal must stipulate that it is predicated upon all the terms and conditions of this RFQ. In addition, it must contain a statement to the effect that it is firm for a period of at least 30 days from the date of receipt by the Government.

https://www.ihs.gov/sexualabuseprevention/training/ mailto:Kimmen.LeBeau@ihs.gov

STATEMENT OF WORK

FOR MEDICAL PHYSICIAN

(OB-GYN)

DESCRIPTION/SPECIFICATIONS/WORK STATEMENT

PURPOSE OF CONTRACT:

The mission of the Fort Thompson IHS Health Center is to provide the best possible health care services to the Native American population of the Crow Creek Reservation in South Dakota. To meet this mission this requires contractor support provide OB/GYN physician services on an intermittent basis at the health center.

The Fort Thompson IHS Health Center requires assistance in the recruitment and placement of a Board Certified or Board Eligibility OB/GYN physicians on the medical staff for temporary duty assignments. The purpose of the contract is for the recruitment; credentialing and placement of OB/GYN physician for the Fort Thompson IHS Health Center.

The contract is a Lowest Priced Technically Acceptable Non-Personal Health Care services contract, as defined at FAR part

37.01 under which the contractor is an independent contractor and shall allow the Government to evaluate the quality of professional and administrative services provided, but retains no control over the medical, professionals aspects of the services rendered (e.g., professional judgments, diagnosis for specific medical treatment).

Non-Personal Service Contract is established to provide OB/GYN physician services.

Contractor will work 2 day per month; 8 hours per day totaling 16 hours per month at the Fort Thompson IHS Health Center in Fort Thompson, South Dakota. The contractor will perform according to the statement of work.

The Contractor shall indemnify the Government for any liability producing act or omission by the contractor its employee and agents occurring during contract performance. The Contractor shall maintain medical liability insurance in the coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned.

The contractor shall furnish 0B/GYN physicians for primary care assignments in the Fort Thompson SD as requested. Contract physician care shall cover the range of OB/GYN primary care typically provided in a rural civilian practice of similar size. The Contractor shall provide physicians to perform the necessary medical procedures; the contractor shall locate, credential, and have available sufficient staffing to provide primary care physician coverage on a regular work schedule.

Upon the receipt of contract, the contractor shall locate, credential, and have available sufficient staffing to provide primary care physician coverage on a regular work schedule. OB/GYN work schedules are exclusive of week-ends and all federally established holidays.

FOR MEDICAL PHYSICIANS

(OB/GYN)

The standards of medical practice and duties of the contractor through its physicians shall be determined pursuant to the governing body bylaws, medical staff bylaws, rules and regulations of the Indian Health Service, applicable provisions of law including but not limited to Centers for Medicare, Medicaid Services (CMS) compliance, rules and regulations of any and all governmental authorities related to licensure and regulations of physicians an health care and standards and recommendations of the Accreditation Association for Ambulatory Health Care (AAAHC).

In accordance with the Indian Health Service credentialing policy, the contractor shall complete primary source verification for each OB/GYN physician performing services under the contract. Upon the placement of a primary care physician at Ft Thompson IHS Health Center the physician shall complete a credentials packet and be credentialed by the health center Governing Body. Compliance with the Indian Health Service privileging requirements is essential in the performance of the contract.

Contract physician shall be board certified or eligible, in OB/GYN Practice. Current Basic Life Support (BLS) and Advance Cardiac Life Support (ACLS) certification or equivalent based on specialty is required of all physicians placed by the contractor.

The contractor shall provide OB/GYN physician for the professional management of patients being treated at the Fort Thompson IHS Health Center. The contract physicians shall provide medical support for the outpatient department.

Contract physicians shall generate and maintain proper medical record information on beneficiaries to who treatment is provided in accordance with Indian Health Service, AAAHC and CMS regulations. The contract physician shall prepare all medical record documentation exclusively on the Electronic Health Record (EHR) to meet or exceed the established standards of the IHS facility to include but not limited to: timeliness, legibility, accuracy, content and signature. All medical recording information and documentation generated in the performance of this contract must be completed at time of departure and will remain the property of and subject to the exclusive control of the Indian Health Service.

The health center shall provide all blank government forms applicable to the Indian Health Service. The health center personnel will provide an appropriate orientation to the necessary forms. In addition, the contract provider and support staffs are required to document patient care utilizing the Electronic Health Record. An orientation to the EHR will be given by the Clinical Applications Coordinator (CAC).

The contractor will provide their own support personnel to assist them with their clinic, equivalent of a licensed practical nurse or higher.

, STATEMENT OF WORK

(OB/GYN)

The contractor will provide quarterly peer review on its providers and present this information to be maintained with the project officer by the second week of the 1st month after the quarter ends. Peer Reviews are conducted every three months based on the fiscal year of (October 1st through December,31st, January 1st through March 31st, April 1st through June 30th and July 1st through September 30th).

The "Unit Price" is an all inclusive cost. All "inclusive costs" 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 purchase order

Period of Performance will be 07/01/2021 through 06/30/2026.

Contractor's agreement is hereby incorporated by reference as part of this contract. In event of conflict between any terms of the agreement and the contract, applicable federal laws and statues will prevail. This contract obligates funds.

Base year 07/01/2021 - 06/30/2022; Option year one (1) 07/01/2022 - 06/30/2023;

Option year two (2) 07/01/2023 - 06/30/2024; Option year three (3) 07/01/2024 - 06/30/2025 and Option year four (4) 07/01/2025 - 06/30/2026.

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;

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. Contract name (where practicable), title and telephone number.

The individual providing services under this contract which involves regular contact with or control over Indian children, are subject to a character investigation in accordance with the Indian Child Protection and Family Violence Prevention Act P.L. 101-630.

The contractor must perform in accordance with section 231 of the Crime Control Act of 1990, P.L. 101-647. Failure to comply with these statues will result in immediate removal.

NOTE: All contractor fingerprints will need to be completed and cleared by the HSPD-12 office at the Indian Health Service, Aberdeen Area Human Resources Department prior to contractor working with patients.

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 FD258. 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 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 Time and Materials, LaborHour or Cost Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. 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 contractor's suitability clearances. However, multiple investigations for the same position may, at the Contracting Officer's discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation{s).

http://exclusions.oig.hhs.gov/

GOVERNMENT FURNISHED PROPERTY, FACILITIES AND SERVICES:

The contract physician shall be assigned to the Ambulatory Clinic in which space for personal belongings shall be provided. The contract physician will be authorized to use all areas of the medical treatment facility available to civil service and commission personnel in similar positions. The same restrictions apply to the Contractor as any other Indian Health Service personnel to use these areas for official business activities only.

The contract 0B/GYN physician will be authorized to use all administrative and professional support available to Indian Health Service personnel. This will include but not limited to copy machines, fax machines, medical library, and telephone services.

The same restrictions to use these items for official Indian Health Service business apply.

The health center shall provide all medical and non-medical equipment and supplies used in the Fort Thompson IHS Health Center for the care and management of patients.

The health center shall provide an ongoing method of monitoring and evaluation of the quality and appropriateness of patient care and identifying deficiencies in the quality service performed before the level of performance becomes acceptable.

The health center shall provide to the contract physician and support staff a contractor orientation to the health center, of which must be completed timely.

CONTRACTOR FURNISHED EQUIPMENT. FACILITIES AND SERVICES:

The Fort Thompson IHS Health Center does not anticipate a need for contractor furnished equipment.

The contract licensed OB/GYN physician and support staff shall provide his or her own uniforms.

INSPECTION BY THE GOVERNMENT:

Maintains records and reports on patients and other required information for use in program operation, quality assurances and other purposes. Quality of documentation will be subject as part of a total quality management, quality assurance and quality improvement program.

PERFORMANCEBASE AND FEE DETERMINATION:

Fee to be dispersed upon completion of each week of contracting period . Fee will be paid on a per diem basis, with a standard of 8 hour workday. The Contracting Officer Representative or their designee will verify the delivery of services.

As a requirement of this contract, the contractor will use the Standard of Care for Obstetrical and Gynecological services to meet the level of performance-base by completing quarterly reviews on each medical provider and submitting the unbiased results to the Clinical Director or Project Officer of the contract.

CONTRACTORS PERFORMANCE CONDITIONS & RESPONSIBITLIES:

1. Contractor is responsible for reporting all taxes from wages under this contract to the appropriate State and Federal Agencies, provided the awardees is an individual.

2. Contractor is responsible for his/her won reliable transportation in the performance of the contract.

3. Contractor is responsible for Fringe Benefits and other benefits such as health, retirement, etc. for his/her employees, if other than self.

4. Contractor is responsible for maintaining satisfactory standards of competence, conduct, appearance and integrity. The quality of work performance of the contractor shall be subject to review.

5. Contractor is responsible for notifying the designated supervisor/director if he/she will be late, ill or unable to work for other reasons.

Contractor earns no leave and is compensated only for hours actually worked at the agreed compensatory rate.

7. Contractor is responsible for signing-in and signing-out of immediate work area, utilizing in-house system of accountability.

The contractor shall establish a reporting system that includes significant findings, major problems encountered and plans for their resolution, number of physicians placed by service unit, amounts billed to the service unit, and other workload information.

The contractor shall establish an invoicing system compatible with the Federal Acquisition Regulation (FAR) Prompt Payment policy.

(OB/GYN)

REQUIRED COMPLIANCE WITH THE INDIAN CHILD PROTECTION AND

FAMILY VIOLENCE PREVENTION LAW P. L. 101-630 AND CRIME CONTROL

ACT P. L. 101-647:

The contractor is prohibited from having any unsupervised contact with Indian Children in the performance of this contract unless:

1. They act under the direct supervision and within the sight of a Government employee who has obtained a satisfactory "Criminal History Check" in accordance with the "Indian Child Protection and Family Violence Prevention" P. L. 101-630 and "Crime Control Act" P. L. 101-647.

Prospective contractors who duties and responsibilities involve regular contact or control over children are subject to a character investigation as required P. L.

101-630. The Indian Child Protection and Family Violence Prevention Act. The I HS personnel offices will conduct these investigations following award of a contract. The character investigations may be waived if, in judgment of the Contracting Officer, in consultation with the Personnel Officer, and investigation has already been conducted and is on file. Until the character investigation has been completed and the Contracting Officer notified or the results, the Contractor must not have unsupervised contact with Indian Children.

2. The contractor has obtained a satisfactory "Criminal History Check" which satisfies the requirements for the "Indian Child Protection and Family Violence and Prevention Law" P. L. 101-630 and "Crime Control Act" P. L. 101-647.

(For the purpose of this contract, the Clinical Director or designee will act as the Project Officer and serve as the contractor's supervisor in compliance with Item No.1 above and satisfies P. L. 101-630 and P. L. 101-647)

AGREEMENT TO A TEMPORARY WAIVER OF CHARACTER INVESTIGATIONS:

STATEMENT OF WORK -

OB/GYN

04/21/2021

1./7#

.... "f� (

Indian Health Service Office of Human Resources

Memorandum

To:

From:

Subject:

Date:

Supervisor of child care covered position incumbent Human Resources/Personnel Security Office Child Care Position Provisional Authorization

This is notice you will supervise a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. The Indian Health Service is required to compile a list of all authorized positions with duties and responsibilities that Involve regular contact with or control over Indian children and investigate the character of each individual who is employed or is being considered for employment in such a position. The requirement is that the individual is to be under the supervision and in sight (chaperoned) of a previously investigated staff person (favorably adjudicated).

The position and individual identified below has been designated as a covered position and has been granted provisional authorization:

Name:

Position title:

The following criteria must be met for the above mentioned individual:

► Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

► Continue with processing of background investigation - Tier 1 with child care (minimum).

► Provide requested documentation/information as requested from the Personnel Security/HR

Office.

Employee/Contractor/Affiliate must be 100¾ chaperoned at all times by a staff person and/or alternates who have at a minimum a favorably adjudicated Tier 1 with child care (Tier 1 C) or CNACI investigation.

The following individuals listed below agree and accept responsibility of the chaperone role.

Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated

I have verified a favorable investigation is on file for identified chaperones:

Personnel Security/HR Office designee Date

Your signature indicates you are accepting responsibility, will comply with the above criteria, and will assure the above named individual will be chaperoned at times while on site.

Department Supervisor/Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in removal and termination of the granted provisional authorization.

Employee/Contractor/Affiliate Date

Declaration for Federal Employment"'

('Thia form may also be used to eases& fltneu ror federal contract employment) form Al)prove<l:

0MB No 3206-01$2

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

The Information collected on lhls form Is used to determine your acceptablllty for Federal and Federal contract employment end your enrollment status In lhe Government's Life Insurance program. You may be asked to complete this form et any lime during the hiring process. Follow Instructions lhel the agency provides. If you ere selected, before you are appointed you wlll be asked to Update your responses on this form end on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this dec laratlon or attached fom,s or sheets may be grounds for not hiring you, or for flrlng you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, tltle 18, section 1001).

Either type your responses on this form or print clearly In dark Ink. If you need addition el space, attach letter-size sheets (B.6" 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 authOrlzed to request this Information under sections 1302, 3301, 3304, 3328, and 8716 or title 6, U.S. Code. Sectlon 1104 of tllle 5 allows the Office ot Personnel Management 10 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 sultablllty or your ability to hold a security clearance, and II may be disclosed to authorized offlclels 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 dale. Public Law 104-134 (Apr/I 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 appllcellon. Incomplete addresses end ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure or this record or Information In this record Is In accordance with routine uses found In System Netice OPM/GOVT-1, General Personnel Record�. This system allows disclosure of Information to: training faollllles; organizations deciding claims for retirement. Insurance. unemployment, or health benefits; officials In lillgatlon or administrative proceedings where the Government Is a party; law enforcement agencies concerning e vlolntlon or law or regulallon; Federal agencies for stallslical reports and studies: oHicials of labor organizations recognized by law In connection with representation of employees; Federal agencies or olher sources requesting Information for Federal agencies In connecllon with t'llrlng or ratalnlng, security clearance.

securlly or sullablilty lnvostiga!ions, classifying Jobs, contructing, or Issuing licenses. grants, or olher banellls; public and private organizations, Including news media, which grant or publicize employee recognitions and awards; the Maril Systems Protection Ooard, the Office of Special Counsel, the Equal EfTlployment Opportunity Commission. the Federal Labor Rolellons Authority, Iha National Archives and Records Adtninlstretlon, end Congressional offices In connection with their officla.l functions; prospective non-Federal employers concerning tenure of employment, clvU service status, length of service, end lhe date ond noture of action for separation as shown on the sr- 50 (or authorized exception) of a specifically Identified Individual: requesting organizations or Individuals concerning the home address and other relevant information on those w110 mlgM have contracted en Illness or been exposed to a health hazord; authorized Federal and non-Federi:il agencies for use In computer matching: spouses or dependent children asking whether the employee has changed from a sell-and•famlly to a sell-only hea!th benents enrollment; lndlvldueh;

working on a contract, service, grant, cooperative agreemenl. or job for the Federal government; non-agency members of en agency's performance or other panel; and agency-appointed representaHves or employees concerning Information Issued to the en1ployees about fitness-for-duty or agency-flied dlsablllty rellroment procedures.

Publlc Burden Statement ----------------------------•

Public burden reporting for this collecllon of Information Is estimated lo vary rrom 5 to 30 minutes with an average of 15 minutes per response, Including time for reviewing 1nstn1c1lons, searching existing data sources. gathering the data needed, and complellng and reviewing the collectlon of information. Send comments regarding the burden esllmete or any olher aspect of the collection of Information, Including suggestions for reducing lhls burden, to lhe U.S. Office of Personnel Management, Reports and Forms Manager (3206-0102), Washington, DC 20415-7900. The 0MB nurnber, 3206-0102, Is valid. OPM may (101 coltec;t this Information, and you are not required lo respond, unless this number Is displayed, U.S. Office of Personnel Management 6 U 9 C 1302, 3301, 3�, 3328 & 8718

�form"°6 R•vl>ed Ociober 2011

Provk>u■ edllk>n1 0010/ole and unuub/o

Declaration for Federal Employment* ("This form may also be used to 11&eeu mne88 for federal contraot employment)

GENERAL INFORMATION

fom, /.pproved:

0MB No. �206--0182

1. FULL NAME (Provide your full name. If you h11ve only Initials in your name, provide them and Indicate "Initial only". If you do not have I middle name Indicate "No Middle Name", If you ara a "Jr.," "Sr.," etc. enter this under Suffi>1, First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3b, ARE YOU A U.S. CITIZEN?

3a. PLACE OF BIRTH (Include city and state or country)

J YES I. NO (lf"NO", provide country of citizenship) ♦

4, DATE OF BIRTH (MM/0D/YYYY)

6, OTHER NAMES EYER USEC (For example, maiden name, nickname, elo) 6, PHONE NUMBERS (Include area codes)

Selective Service Registration

Doy ♦

Night ♦

If you are a male born after December 31, 1959, and are at least 1 B years or age, civil service employment law (5 U,S,C, 3326) 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? ,:; YES r/ NO (If "NO", proceed to 8.)

7b. Have you registered With the Selective Service System? 1: YES (lf"YES", proceed to 8.) r: NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) In Item 16.

MIiitary Service 6, Have you ever served In the United States military? L,, YES (If "YES", provide tnronmetlon below) 1· NO

If you answorod "YES,• I/st the branch, dates, and type of dlschafTJfl for all active duty.

If )'our oll/)1 active duty was trlllnlng In the Reserves or Notional Guard, answer "NO,"

Branch From (MM/D0/YYYY) To IMM/00/YVYY) Type of Discharge

Background Information

For ell quoetlone, provide all additional requeetod Information under ltom 16 or on attachod eheots. The clrcumsIonce.s of eoch event you list wlll be considered. However, In most cases you can sllll be considered for Federal jobs.

for questions 9, 10, and 11, your answers should Include corwte1lons resultlng from a plea of nolo contondere (no contest}, but omll (1) lrllfOu fines of $300 or less, (2) any vlolallon of law commlllod befote your 16th birthday, (3) aoy violation of law committed before your 10th blnhdey Jr nnalty decided In fuvonlle court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or slmilar slate law, and (6) any convicllon for which the record was expunged under Federal or state law •

o. During the lest 7 years, have you been convicted, been Imprisoned, boon on probation, or been on parole? r· YES /! NO (Includes felonies, nreorrns or explosives vlolotlons, mlsdomoenors, and an other offenses.} If "YES,• use ffem 16 to provi<ltJ tho <Joto, exp/anal/or, of tllo vlo/11/ion, ploco of occurronca. anct Illa nomo and addross of tho police department or court Involved.

1 o. Have you been convicted by a mlllta,y cou,1-martlal In the pest 7 years? (If no m/11/ary service, answer "NO.") If "YES,• usu //1:1111 1 (J 10 pro Ide /he data, 01<plonatlon of I/lo violo//on. p/11c nf nccurronoo, end Iha name and address of tho mllitary authority or courl lnvo/Vod,

11. Aro you currently undor charges for any vlototlon or 1ow? If "YES," 11so /tom 16 to provide tho date, oxplonof/on of fho v/olol/on, ploco of occe1rroni;e, end the name and uddross of the po/loo doparlmont or court /11volvod.

12. During the lost 6 years, heve you been fired from any fob for an>' reason, did you quit alter being told that you would be fired, did you leevti any job by mutual agr-eement because of specific problems, or were you debarred (rom federal employment by tho Office of Personnel Menegomenl or any other Federal agency? If "YES,'' use I/om 16 to provide tho da/o, an oxplonallon of the prob/om, reason for /uovlng, end f/Ju employers name and oddmss.

13. Are you delinquent on eny Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of bonents, end other debts to the U.S. Government, plus dofavlts of Federally guaranteed or Insured loans such os student end homo mortgage loans.) If "YES," use !tam f6 to provfdo tho typo, lonr,th, and amount ofthe t10ll111wo11cy or dRfou/1, and stops /hat you ora taking lo correct 1/IO error or ropoy /ho dobt.

r n

Yl;S I. NO

YES ,1 NO

YES ,, NO

YES I NO

U.S. Office of Personnel Management 6 U 6 C 1302, 3301, 3»!, 3328 a. 8715

Op10,01f FCl<ffl X,O ROYllod QclObtl 2011 f'1ovtov1 edMon.t «,1olet1 ind Ur'IJHbla

Declaration for Federal Employment* ('Thia lorm mey also be ueed to aHeU fitness for re de rel contract employment, Additional Questions fom, /.jlptOYod:

0MB No, 320e-0l82

14. Do any of your relalivas work for the agency or government organization 10 which you are submitting th/a form?

r(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, . YES I NO father-In-law.mother-In-law, son-In-law, daughter-In-law, brother-In-law, sister-In-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and hall sister.) If "YES,• use flam 16 to provide the re/a/Ive"s name, relationship, and the department, agency, or branch of the Armed Forces for which your ro/atlve worns.

15, Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay baaed on mllltary, 1 YES r NO Federal civilian, or District of Columbia Government service?

Continuation Space/ Agency Optional Questions ------------------- 1e, 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 eny questions are printed below, please answer as Instructed (these questions are speo/fio to your position and your agency Is authorized to ask them).

Certifications I Additional Questions

APPLICANT: If you are apply Ing for a position and have not yet been ■elected, carefully review your answers on this form and any attached sheets, When !his form and all attached materials are accurate, read Item 17, and complete 17a.

APPOINTEE: If you are being oppolntod, carefully review your answers on this form and any attached sheels, Including any other appllcatlon materlols that your agency has attached to this form. If any information requires correction to be occurate as of the date you are signing, make changes on this form or lhe ahachmenls andfor provide updated Information on addlUonal sheets, lnltlrillng and dating ell changes and additions.

When this form and all attached materials ere accurate, read Item 17, C-Ompleta 17b, read 1 B, end answer 18a, 18b, and 10c as appropriate.

17. I certify that. 10 lho best or my knowledge end belier, all of the lnrormetlon on and elteched to this Declaratlon for Federal Employment, Including any aUached applicaHon materials, la true, correct, complete, and made In good faith. I undel"ltand that a falao or fraudulenl answer to any question or item on any part of this declaration or Its attachmonts may bo grounds for not hiring mo, or for firing me after I bogln work, and may be punishable by fine or lmprleonment. I understand thal any Information I give may be investloated for purposes of determining ellglbl\lly for Federal employment as allowed by law or Presldenlle\ ardor. I consent to the release of Information about rny ability and lilness for Federal employment by employers, schools, law enforcement agencies, and other lndlvlduels and oroanlzalione 10 lnvestlga10,s, personnel sµeclalist&, end other authorized employees or representallves of the Federal Govemmenl. I understand that for financial or lending \nstilutions, medlcal Institutions, hospitals, health care professtonals, and some other sourcos of Information, a separate spec!t1c release may be needed, and I mey be contacted for such e release al a late, date.

Appointing Offic11r:

17a. Applicant's Signature: .,,,.,.-----------------

(Sign In Ink) Date ______ _ En111 0'1• or ,lj>polnl/nonl 01 Corwt11lon

17b, Appointee's Signature:�---,�,-,--------------- (Sign In Ink)

Date _____ _

MMIDDIYYYY

18. Appolntoe (Only respond It you have boon employed by the Federal Government before); Your eleellons of life Insurance during previous Federal employment may effecl your ollg\blllly for life Insurance during your new appointment. These questions are asked to help your personnel office.make a correct determination.

18a. \!Vhan did you leave your last Federal Job?

MM/00/YYYY

DATE:

16b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life Insurance?

I, YES

1 Be, If you answered "YES" to Item 18b, did you later cancel the waiver(s)? If your answer lo Item r: YES 16c Is "NO," use Item 16 to Identify the type(s) of Insurance for which waivers were not ··· canceled.

U.S. Office of Personnel Management 6 U s,c, 1302, 3301, 3»4, 3320 "8710 r NO I DO NOT KNOW

I NO I DONOTKNOW

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Rovlltd O<M>er 2011

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0MB Approved Form No. 0917-0028 Expiration Date: 2/28/2022

Addendum to Declaration for Federal Employment (OF 306)

Indian Health Service

Child Care & Indian Child Care Worker Positions

Item 16. Agency Specific Questions

Name: ____________ _ Social Security Number: _______ _ (Please print)

Job Title in Announcement: Announcement Number:

Section 231 of the Crime Control Act of 1990, Public Law (Pub. L.) 101-647, requires 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, Pub. L. 101-630, 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 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:

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

YES NO

[If "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.]

CLAUSES INCORPORATED BY REFERENCE

(Firm Fixed-Price, Non-Personal Healthcare Service, Commercial)

FAR CITATION: 52.252-2: Clauses Incorporated by Reference. (FEB 1998) I. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses

No. FAR Citation Clause Title Clause Date ____

1. 52.202-1 Definitions June 2020

2. 52.203-3 Gratuities April 1984

3. 52.203-7 Anti-Kickback Procedures June 2020

4. 52.203-12 Limitations on Payments to Influence Certain June 2020 Federal Transactions

5. 52.203-17 Contractor Employee Whistleblower Rights June 2020 And Requirement to Inform Employees of Whistleblower Rights

6. 52.204-4 Printed or Copied Double-Sided on Recycled May 2011 Paper

7. 52.204-7 System for Award Management October 2018

8. 52.204-9 Personal Identity Verification of Contractor January 2011 Personnel

9. 52.204-13 System for Award Management Maintenance October 2018

10. 52.204-16 Commercial and Government Entity Code July 2016 Reporting

11. 52.204-18 Commercial and Government Entity Code August 2020 Maintenance

12. 52.204-19 Incorporation by Reference of December 2014 Representations and Certifications

13. 52.204-24 Representation Regarding Certain October 2020 Telecommunications and Video Surveillance Services or Equipment

14. 52.212-1 Instructions to Offerors – Commercial Items June 2020

15. 52.212-4 Contract Terms and Conditions October 2018

- Commercial Items

16. 52.224-1 Privacy Act Notification April 1984

17. 52.224-2 Privacy Act April 1984

18. 52.232-39 Unenforceability of Unauthorized Obligations June 2013

19. 52.232-40 Providing Accelerated Payments to Small December 2013 Business Subcontractors

20. 52.233-3 Protest after Award September 2006

21. 52.233-4 Applicable Law for Breach of Contract Claim October 2004

22. 52.237-1 Site Visit April 1984

23. 52.237-2 Protection of Government Buildings April 1984 Equipment, and Vegetation

24. 52.237-7 Indemnification and Medical Liability Insurance January 1997

25. 52.253-1 Computer Generated Forms January 1991

CLAUSES INCORPORATED IN FULL TEXT

II. Federal Acquisition Regulations (FAR) (48 CFR Chapter 1) Clauses

No. FAR Citation Clause Title Clause Date ____

1. 52.204-24 Representation Regarding Certain October 2020 Telecommunications and Video Surveillance Services or Equipment

2. 52.209-11 Representation by Corporations Regarding February 2016 Delinquent Tax Liability or a Felony Conviction Under any Federal Law

3. 52.212-3 Offeror Representations and Certifications February 2021 (See attached)

4. 52.212-5 Contract Terms and Conditions Required To January 2021 Implement Statues or Executive Orders – Commercial Items (See attached)

5. 52.216-18 Ordering October 1995

6. 52.216-19 Order Limitations October 1995

7. 52.216-22 Indefinite Quantity October 1995

8. 52.217-5 Evaluation of Options July 1990

9. 52.217-8 Option to Extend the Services November 1999

10. 52.217-9 Option to Extend the Term of the Contract March 2000

11. 52.225-25 Prohibition Contracting with Entities Engaging June 2020 In Certain Activities or Transactions Relating To Iran-Representation and Certifications

12. 52.232-18 Availability of Funds April 1984

13. 52.232-19 Availability of Funds for the Next Fiscal Year April 1984

14. 52.233-2 Service of Protest September 2006

15. 52.252-1 Solicitation Provisions Incorporated by February 1998 Reference

16. 52.252-2 Clauses Incorporated by Reference February 1998

52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment.

As prescribed in 4.2105(a), insert the following provision:

REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO SURVEILLANCE SERVICES OR EQUIPMENT (OCT 2020)

The Offeror shall not complete the representation at paragraph (d)(1) of this provision if the Offeror has represented that it "does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract, subcontract, or other contractual instrument" in paragraph (c)(1) in the provision at 52.204-26, Covered Telecommunications Equipment or Services—Representation, or in paragraph (v)(2)(i) of the provision at 52.212-3, Offeror Representations and Certifications-Commercial Items.