SF-18.doc

REQUEST FOR QUOTATIONS

(THIS IS NOT AN ORDER)

THIS RFQ FORMCHECKBOX

IS FORMCHECKBOX

IS NOT A SMALL BUSINESS SET-ASIDE,

IT IS A FEDERAL SUPPLY SCHEDULE SET-ASIDE

PAGE OF PAGES

1 2

1. REQUEST NO.

RFQ-18-094

2. DATE ISSUED

8/31/2018

3. REQUISITION/PURCHASE REQUEST NO.

Manual Req. #036-2018-0115

4. CERT.FOR NAT. DEF.

UNDER BDSA REG.2

AND/OR DMS REG. 1

RATING

5A. ISSUED BY

Great Plains Area Indian Health Service, Room 309, Federal Building, 115 4th Avenue SE, Aberdeen, South Dakota 57401-4381

6. DELIVER BY (Date)

FORMCHECKBOX

FOB DESTINATION FORMCHECKBOX

(See Schedule)

NAME

Susan K. Davis, Contract Specialist

AREA CODE

NUMBER

226-7572

a. NAME OF CONSIGNEE

Fort Thompson

TO:

b. STREET ADDRESS 1323 BIA, Rte. #4, PO Box 200

a. NAME

b. COMPANY

c. CITY

Ft. Thompson

c. STREET ADDRESS

d. CITY

e. STATE

f. ZIP CODE

d. STATE

SD

e. ZIP CODE

57339

10. PLEASE FURNISH QUOTATIONS TO

THE ISSUING OFFICE IN BLOCK

5a ON OR BEFORE CLOSE OF

BUSINESS (Date) September 13, 2018 @ 1:00pm CST IMPORTANT: This is a request for information, and quotations furnished are not offiers. If you are unable to quote, please so indicate on this form and return it to the address in Block 5a. This request does not commit the Government to pay any costs incurred in the preparation of the submission of this quotation or to contract for supplies or services. Supplies are of domestic origin unless otherwise indicated by quoter. Any representations and/or certifications attached to this Request for Quotations must be completed by the quoter.

11. SCHEDULE (Include applicable Federal, State and local taxes)

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

Firm Fixed-Price, Non-Personal Services, IDIQ, Health Care Contract for an Oral Surgeon to provide Services at the Fort Thompson IHS Health Center in Ft Thompson, SD and the Wagner IHS Health Center; in Wagner, SD.

The contractor is to perform in accordance with the attached Statement of Work and Performance Work Statement Standards.

The period of performance will be from Date of Award to August 31, 2019 for the base year and option years from:

OY#1 – September 1, 2019 – August 31, 2020 OY#1 – September 1, 2020 – August 31, 2021 OY#1 – September 1, 2021 – August 31, 2022 OY#1 – September 1, 2022 – August 31, 2023

12. DISCOUNT FOR PROMPT

PAYMENT

a. 10 CALENDAR DAYS

b. 20 CALENDAR DAYS

c. 30 CALENDAR DAYS

d. CALENDAR DAYS

NOTE: Additional provisions and representations FORMCHECKBOX are FORMCHECKBOX are not attached.

SIGN QUOTATION

15. DATE OF

QUOTATION

a. NAME OF QUOTER

b. STREET ADDRESS

c. COUNTY

16. SIGNER

a. NAME (Type of print)

b. TELEPHONE

AREA CODE

AUTHORIZED FOR LOCAL REPRODUCTION

FormFlow/Delrina Inc.

STANDARD FORM 18 (REV 6-95)

Previous edition not usable

Prescribed by GSA-FAR (48 CFR) 53-215-1(a)

CONTINUATION FOR RFQ 18-094

ITEM NO.

(a)

SUPPLIES/SERVICES

(b)

QUANTITY

(c)

UNIT

(d)

UNIT PRICE

(e)

AMOUNT

(f)

1.

Onsite Oral Surgeon Services six (6) times per year with 2 – 8 hour days per each session with one day at the Fort Thompson IHS Health Center, 1323 BIA Rte. 4, Box 200, Fort Thompson, South Dakota 57339; and one day at the Yankton-Wagner IHS Health Center, 110 Washington Ave., N.W., Wagner, South Dakota 57380;

Scheduling to be coordinated with the Chief of the Dental Department and/or their designee;

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

ATTACHMENTS:

· Statement of Work

· Performance Work Statement

· Business Associate Agreement

· Contractor’s Performance Conditions & Responsibilities

· Special General Memorandum 2015-03 Mandatory Seasonal Influenza Immunization for Civilian Health Care Personnel Working in Indian Health Service Health Care Facilities

· Courtesy & Respect in the Workplace

· Standards of Ethical Conduct with Employee Certification

· HHS Residual Standards of Conduct

· Title 5 Code of Federal Regulations – Chapter XLV – DHHS – Part 5501 Supplemental Standards of Ethical Conduct for Employees of the DHHS

· Workplace Violence

· Violence in the Workplace

· Provisions and Clauses incorporated in full text

· Provisions and Clauses incorporated by reference

· Past Performance Form (to be copied as needed)

· Agreement to a Temporary Waiver Provisional of Character Investigation form

· OF-306 Declaration for Federal Employment

· OF306 Addendum to Declaration for Federal Employment

DUN & Bradstreet Number:

(The Dun & Bradstreet number is required. Provided you do not have one, you may call 866-705-5711 and obtain a number.)

The Quoter is hereby notified that they must be registered in the System for Award Management (SAM) before the Government will issue an award. (You may do this by going to www.sam.gov to register. You are required to update this registration every year prior to the expiration date.)

FEDERAL TAX ID NUMBER:

EMAIL ADDRESS:

NET TERMS:

Sessions

Each

Total