RFQ-21-103 - Dentist Services.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-21-103.

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 a Small Business solicitation and the associated NAICS Code is 621210, which has a small business standard of $8.0.

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 15, 2021 through July 14, 2022, 1872 Hours x $_________/Hour, totaling $__________.

2. Option Year One (1): July 15, 2022 through July 14, 2023, 1872 Hours x $_________/Hour, totaling $__________.

3. Option Year Two (2): July 15, 2023 through July 14, 2024, 1872 Hours x $_________/Hour, totaling $__________.

4. Option Year Three (3): July 15, 2024 through July 14, 2025, 1872 Hours x $_________/Hour, totaling$__________.

5. Option Year Four (4): July 15, 2025 through July 14, 2026, 1872 Hours x $_________/Hour, totaling $__________.

F. Provide a Dentist for Dental Services Monday through Thursday 8:00am - 4:30pm and/or Friday 8:00am - 12:00pm.

G. See attached Statement of Work. Services will be provided for the Fort Yates IHS Hospital, Fort Yates, North Dakota 58538 or the McLaughlin IHS Health Center, McLaughlin, South Dakota 57642. The period of performance will be July 15, 2021 through July 14, 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-21-103;

2. Closing Date: July 9, 2021 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 July 7, 2021, 10:00am 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 http://www.acquisition.gov/ mailto:wenda.wright@ihs.gov http://exclusions.oig.hhs.gov/ 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 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.

“Dentist(s) will arrive on a Business Day ONLY to complete all Orientation and Background procedures. The Clinical Director or Designee will ensure all Orientation and Background procedures have been completed and an email will be sent to the Contracting department to state as such. The Dentist(s) will NOT see patients until Background/Fingerprints have been cleared.”

“The standards of medical practice and duties of the Contractor through its Dentist(s) shall be determined pursuant to the bylaws of the Service Unit. The regulations of the hospital, applicable provisions of law, other rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals must be followed. Also the standards and recommendations of Centers for Medicare and Medicaid Services (CMS) or the Accreditation Organization must be adhered to. The Contract Dentist(s) shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care.”

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

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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

OpOorelF<>rm30I!

Rovlltd O<M>er 2011

Pr11vlou11dlllon1 ob1olat1 and um11l>l1

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

14. 52.212-4 Contract Terms and Conditions October 2018

- Commercial Items

15. 52.217-5 Evaluation of Options July 1990

16. 52.217-8 Option to Extend the Services November 1999

17. 52.224-1 Privacy Act Notification April 1984

18. 52.224-2 Privacy Act April 1984

19. 52.232-39 Unenforceability of Unauthorized Obligations June 2013

20. 52.232-40 Providing Accelerated Payments to Small December 2013 Business Subcontractors

21. 52.237-1 Site Visit April 1984

22. 52.237-2 Protection of Government Buildings April 1984 Equipment, and Vegetation

23. 52.237-7 Indemnification and Medical Liability Insurance January 1997

24. 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. 52.209-5 Certification Regarding Responsibility Matters August 2020

3. 52.209-7 Information Regarding Responsibility Matters October 2018

4. 52.209-11 Representation by Corporations Regarding February 2016 Delinquent Tax Liability or a Felony Conviction Under any Federal Law

5. 52.212-3 Offeror Representations and Certifications February 2021 (See attached)

6. 52.212-5 Contract Terms and Conditions Required To January 2021 Implement Statues or Executive Orders – Commercial Items (See attached)

7. 52.216-18 Ordering October 1995

8. 52.216-19 Order Limitations October 1995

9. 52.216-22 Indefinite Quantity October 1995

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

11. 52.232-18 Availability of Funds April 1984

12. 52.232-19 Availability of Funds for the Next Fiscal Year April 1984

13. 52.233-2 Service of Protest September 2006

14. 52.252-1 Solicitation Provisions Incorporated by February 1998 Reference

15. 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. The Offeror shall not complete the representation in paragraph (d)(2) of this provision if the Offeror has represented that it "does not use covered telecommunications equipment or services, or any equipment, system, or service that uses covered telecommunications equipment or services" in paragraph (c)(2) of the provision at 52.204-26, or in paragraph (v)(2)(ii) of the provision at 52.212-3.

(a) Definitions. As used in this provision—

Backhaul, covered telecommunications equipment or services, critical technology, interconnection arrangements, reasonable inquiry, roaming, and substantial or essential component have the meanings provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

(b) Prohibition.

(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub.

L. 115-232) prohibits the head of an executive agency on or after August 13, 2019, from procuring or obtaining, or extending or renewing a contract to procure or obtain, any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. Nothing in the prohibition shall be construed to— https://www.acquisition.gov/far/part-4#FAR_4_2105 https://www.acquisition.gov/far/part-52#FAR_52_204_26 https://www.acquisition.gov/far/part-52#FAR_52_212_3 https://www.acquisition.gov/far/part-52#FAR_52_204_26 https://www.acquisition.gov/far/part-52#FAR_52_212_3 https://www.acquisition.gov/far/part-52#FAR_52_204_25

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(2) Section 889(a)(1)(B) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L. 115-232) prohibits the head of an executive agency on or after August 13, 2020, from entering into a contract or extending or renewing a contract with an entity that uses any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. This prohibition applies to the use of covered telecommunications equipment or services, regardless of whether that use is in performance of work under a Federal contract. Nothing in the prohibition shall be construed to—

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover telecommunications equipment that cannot route or redirect user data traffic or cannot permit visibility into any user data or packets that such equipment transmits or otherwise handles.

(c) Procedures. The Offeror shall review the list of excluded parties in the System for Award Management (SAM) (https://www.sam.gov) for entities excluded from receiving federal awards for "covered telecommunications equipment or services".

(d) Representation. The Offeror represents that—

(1) It □ will, □ will not provide covered telecommunications equipment or services to the Government in the performance of any contract, subcontract or other contractual instrument resulting from this solicitation. The Offeror shall provide the additional disclosure information required at paragraph (e)(1) of this section if the Offeror responds "will" in paragraph (d)(1) of this section; and

(2) After conducting a reasonable inquiry, for purposes of this representation, the Offeror represents that—

It □ does, □ does not use covered telecommunications equipment or services, or use any equipment, system, or service that uses covered telecommunications equipment or services. The Offeror shall provide the additional disclosure information required at paragraph (e)(2) of this section if the Offeror responds "does" in paragraph (d)(2) of this section.

(e) Disclosures.

(1) Disclosure for the representation in paragraph (d)(1) of this provision. If the Offeror has responded "will" in the representation in paragraph (d)(1) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment—

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the original equipment manufacturer (OEM) or a distributor, if known);

https://www.sam.gov/

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(ii) For covered services—

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the Product Service Code (PSC) of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(1) of this provision.

(2) Disclosure for the representation in paragraph (d)(2) of this provision. If the Offeror has responded "does" in the representation in paragraph (d)(2) of this provision, the Offeror shall provide the following information as part of the offer:

(i) For covered equipment—

(A) The entity that produced the covered telecommunications equipment (include entity name, unique entity identifier, CAGE code, and whether the entity was the OEM or a distributor, if known);

(B) A description of all covered telecommunications equipment offered (include brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); and

(C) Explanation of the proposed use of covered telecommunications equipment and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(ii) For covered services—

(A) If the service is related to item maintenance: A description of all covered telecommunications services offered (include on the item being maintained: Brand; model number, such as OEM number, manufacturer part number, or wholesaler number; and item description, as applicable); or

(B) If not associated with maintenance, the PSC of the service being provided; and explanation of the proposed use of covered telecommunications services and any factors relevant to determining if such use would be permissible under the prohibition in paragraph (b)(2) of this provision.

(End of provision)

52.209-5 Certification Regarding Responsibility Matters.

As prescribed in 9.104-7(a), insert the following provision:

CERTIFICATION REGARDING RESPONSIBILITY MATTERS (AUG 2020)

(a)

(1) The Offeror certifies, to the best of its knowledge and belief, that—

(i) The Offeror and/or any of its Principals–

(A) Are □ are not □ presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any Federal agency;

(B) Have □ have not □, within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) contract or subcontract;

violation of Federal or State antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property (if offeror checks "have", the offeror shall also see 52.209-7, if included in this solicitation);

(C) Are □ are not □ presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any of the offenses enumerated in paragraph (a)(1)(i)(B) of this provision;

(D) Have □, have not □, within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds the threshold at 9.104-5(a)(2) for which the liability remains unsatisfied.

(1) Federal taxes are considered delinquent if both of the following criteria apply:

(i) The tax liability is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted.

(ii) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded.

(2) Examples.

(i) The taxpayer has received a statutory notice of deficiency, under I.R.C. § 6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights.

https://www.acquisition.gov/far/part-9#FAR_9_104_7 https://www.acquisition.gov/far/part-52#FAR_52_209_7 https://www.acquisition.gov/far/part-9#FAR_9_104_5

(ii) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. § 6320 entitling the taxpayer to request a hearing with the IRS Office of Appeals contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights.

(iii) The taxpayer has entered into an installment agreement pursuant to I.R.C. § 6159. The taxpayer is making timely payments and is in full compliance with the agreement terms. The taxpayer is not delinquent because the taxpayer is not currently required to make full payment.

(iv) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under 11 U.S.C. 362 (the Bankruptcy Code).

(ii) The Offeror has □ has not □, within a three-year period preceding this offer, had one or more contracts terminated for default by any Federal agency.

(2) "Principal," for the purposes of this certification, means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions).

This Certification Concerns a Matter Within the Jurisdiction of an Agency of the United States and the Making of a False, Fictitious, or Fraudulent Certification May Render the Maker Subject to Prosecution Under Section 1001, Title 18, United States Code.

(b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any time prior to contract award, the Offeror learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.

(c) A certification that any of the items in paragraph (a) of this provision exists will not necessarily result in withholding of an award under this solicitation. However, the certification will be considered in connection with a determination of the Offeror’s responsibility. Failure of the Offeror to furnish a certification or provide such additional information as requested by the Contracting Officer may render the Offeror nonresponsible.

(d) Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by paragraph (a) of this provision. The knowledge and information of an Offeror is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.

(e) The certification in paragraph (a) of this provision is a material representation of fact upon which reliance was placed when making award. If it is later determined that the Offeror knowingly rendered an erroneous certification, in addition to other remedies available to the Government, the Contracting Officer may terminate the contract resulting from this solicitation for default.

(End of provision)

52.209-7 Information Regarding Responsibility Matters.

As prescribed at 9.104-7(b), insert the following provision:

https://www.acquisition.gov/far/part-9#FAR_9_104_7

INFORMATION REGARDING RESPONSIBILITY MATTERS (OCT 2018)

(a) Definitions. As used in this provision—

Administrative proceeding means a non-judicial process that is adjudicatory in nature in order to make a determination of fault or liability (e.g., Securities and Exchange Commission Administrative Proceedings, Civilian Board of Contract Appeals Proceedings, and Armed Services Board of Contract Appeals Proceedings).

This includes administrative proceedings at the Federal and State level but only in connection with performance of a Federal contract or grant. It does not include agency actions such as contract audits, site visits, corrective plans, or inspection of deliverables.

Federal contracts and grants with total value greater than $10,000,000 means—

(1) The total value of all current, active contracts and grants, including all priced options; and

(2) The total value of all current, active orders including all priced options under indefinite-delivery, indefinite-quantity, 8(a), or requirements contracts (including task and delivery and multiple-award Schedules).

Principal means an officer, director, owner, partner, or a person having primary management or supervisory responsibilities within a business entity (e.g., general manager; plant manager; head of a division or business segment; and similar positions).

(b) The offeror □ has □ does not have current active Federal contracts and grants with total value greater than $10,000,000.

(c) If the offeror checked "has" in paragraph (b) of this provision, the offeror represents, by submission of this offer, that the information it has entered in the Federal Awardee Performance and Integrity Information System (FAPIIS) is current, accurate, and complete as of the date of submission of this offer with regard to the following information:

(1) Whether the offeror, and/or…