Combined Synopsis_RFQ-24_134 Medical Technologist_Technician.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 Health Care Service, Commercial Item, Purchase Order in response to Request for Quote (RFQ) RFQ-24-134.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2024-06, 08/29/2024.

D. This RFQ is issued as “100% Buy Indian / Small Business,” and the associated NAICS Code is 561320, which has a small business standard of $34.0.

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.

Please complete the list provided below:

Unit Price Total Price

1. Regular Hours: 1,211 Hours at the rate of $: ____________ total $: ____________

2. Call Back Hours: 910 Hours at the rate of $:_____________total $_____________

3. On Call Hours: 588 Hours at the rate of $: ____________total $: ____________

4. Overall total amount $: _________________ F. To provide One (1) Medical Technologist/Technician.

G. To provide for the Standing Rock Service Unit (SRSU), Fort Yates IHS Hospital, Fort Yates, ND. Delivery Location: Fort Yates IHS Hospital, 10 Standing Rock Avenue, Fort Yates, ND 58538. The period of performance will be from the date of award thru 08/31/2025.

H. FAR 52.212-1 Instructions to Offerors-Commercial Products and Commercial Services (September 2023).

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

1. Solicitation number RFQ-24-134.

2. Closing Date: September 13, 2024, at 12:00 pm CDT.

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

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 terms.

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 pertinent 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:

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

Complete and sign Child Care Position/Personnel Security Office form.

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.

Shall meet the Qualifications and Knowledge Requirements in the Performance Work Statement and provide copies of the required documents (if needed).

Copy of current Board Certification

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

Copy of a recent Health Examination.

Copy of Diplomas/Specialty Certifications.

Copies of Continuing Education.

Current CV/resume.

Basis of Award is Lowest Price Technically Acceptable (LPTA). The Government intends to select ONE contractor for award of this effort. The proposals will be initially evaluated by lowest price and if the lowest priced proposal submitted is found to be technically acceptable, no other proposals will be evaluated, and award will be made to the lowest priced, technically acceptable offeror However, if the offeror’s lowest priced proposal is not found technically acceptable, the next offeror’s lowest priced proposal will be evaluated until the lowest priced, technically acceptable proposal is found. The Government intends to evaluate offers and award without discussions.

The Government reserves the right to ask for clarifications from the lowest‐priced offeror being evaluated without approaching other offerors. The Government reserves the right to enter negotiations with the lowest‐priced offeror being evaluated without approaching other offerors.

• Contractor will work within the designated schedule. • Ability to provide at least one available One (1) Medical Technologist/Technician who can be scheduled to work throughout the entire contract or provide a competent replacement provider. • Contractor provides all supporting credential documents as required in the Statement of Work.

I. FAR 52.212‐3 Offer Representations and Certifications‐Commercial Products and Commercial Services (May 2024) See attachment for full text. The Offeror shall complete only paragraphs (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.

J. FAR 52.212‐4 Contract Terms and Conditions‐Commercial Products and Commercial Services (November 2023) – See attachment; Incorporated By Reference.

K. FAR 52.212‐5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders‐ Commercial Products and Commercial Services (May 2024) ‐ See attachment for full text.

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

M. Offers will be accepted electronically, submit via email to the following:

Great Plains Area Indian Health Service Attn: DeAnne Dolphus, Contract Specialist 115 4th Ave. SE, Room 309 Aberdeen, SD 57401 Email: deanne.dolphus@ihs.gov

Questions regarding this solicitation shall be submitted in writing by email by September 10, 2024, 12:00 pm

CDT.

Contractors will need a UEI number and TIN, and they will need to be registered with www.sam.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 of receipt by the government.

The quotation must set forth full, accurate, and complete information as required by the Request for Quotation (RFQ) and be returned no later than the date referenced. All required information must be submitted to be considered responsive and eligible for award.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List (http://exclusions.oig.hhs.gov) throughout the contract. It shall be the contractor's responsibility to notify the acquisition official if the provider changes.

SECURITY CLEARANCE

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

Fingerprints must be completed and adjudicated before services are performed under this contract.

The performance of this contract will require routine access by the contractor's employees or subcontractors to facilities or systems controlled by the Indian Health Service (IHS). Before starting work requiring routine access to IHS facilities or systems, each person must complete an FBI National Criminal History Check (Fingerprint Check) adjudicated by an IHS 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 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 before the start of work, the contractor shall provide the contractor's performance of the work to the Contracting Officer with the names of all individuals to be used in the performance of work for screening against the LEIE. During the performance, the contractor shall provide the Contracting Officer with 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 IHS is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently before 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.

The government will pay for the cost of processing the contractor's suitability clearances. However, multiple investigations for the same position may, at the Contracting Officer's discretion, lead to a reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with IPAs or MOAs to tribal organizations, please click here on the 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, email: Kimmen.LeBeau@ihs.gov.

“Medical Technologist/Technician 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 them as such. The Medical Technologist/Technician will NOT see patients until Background/Fingerprints have been cleared."

“The standards of medical practice and duties of the Contractor through its Medical Technologist/Technician 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 the Centers for Medicare and Medicaid Services (CMS) or the Accreditation Organization must be adhered to.

The Medical Technologist/Technician 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.”

Invoice Processing Platform (IPP)

The Indian Health Service (IHS) has implemented an electronic invoicing system.

In compliance with the Office of Management and Budget (OMB) M-15-19 memorandum “Improving Government Efficiency and Saving Taxpayer Dollars Through Electronic Invoicing” directing Federal agencies to adopt electronic invoicing as the primary means to disburse payment to vendors. Invoices submitted under any award resulting from this solicitation will be required to utilize the Invoice Processing Platform (IPP) in accordance with HHSAR 352.232-71, Electronic Submission and Processing of Payment Requests”

IPP is a secure, web-based electronic invoicing system provided by the U.S. Department of the Treasury’s Bureau of the Fiscal Service, in partnership with the Federal Reserve Bank of St. Louis (FRSTL).

Respondents to this solicitation are encouraged to register an account with IPP if they have not already done so. If your organization is already registered to use IPP, you will not be required to re-register-however, we encourage you make sure your organization and designated IPP user accounts are valid and up to date.

mailto:Kimmen.LeBeau@ihs.gov

The IPP website address is: https://www.ipp.gov.

Please contact the IPP Helpdesk at (866) 973-3131 (M-F 8 AM to 6 PM ET) or IPPCustomerSupport@fiscal.treasury.gov if you require assistance registering or IPP account access.

“Should the contractor feel that use of the IPP would be unduly burdensome, their response to this solicitation should include an explanation of this position for a determination by the contracting officer.”

To:

Subject:

New Hire and Supervisor of position covered by Public Law 101-630 Provisional Authorization- pending favorably adjudicated background investigation

This serves as notice to the supervisor and new hire/contractor/volunteer/affiliate that they will be performing work and/or occupying 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. An individual employed/working or being considered for employment (Federal, contractor, volunteer, or affiliate) at the Indian Health Service with duties and responsibilities involving regular contact with or control over Indian children must undergo a background investigation. Prior to the receipt of a favorably adjudicated background investigation, the individual will have provisional status. At all times whenever Indian children are in the care, custody, and/or control of an individual in a provisional status, the individual is required to be under the supervision and in sight of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

The following individual has been granted provisional authorization for the identified position, which has been designated as a position covered by P.L. 101-630:

Name: _________________________________ Position title: ____________________________ The following conditions must be met for the individual:

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

Continued processing of background investigation – Tier 1 with child care (minimum).

Provide requested documentation/information as requested from the Personnel Security/HR Office.

Supervisor must ensure that new hires/contractors/affiliates who are in a provisional status and have Indian children in their care, custody, and/or control, are within the sight and supervision of a staff person who has a favorably adjudicated background investigation that includes child care coverage.

Supervisors are required to sign indicating your acceptance, responsibility, and compliance with the above criteria, and will ensure that the above named individual is assigned to appropriate personnel whenever Indian children are in their care, custody, and/or control. Failure to comply with the above criteria can result in disciplinary action, up to and including removal.

Department Supervisor/Designee Date

The facility/service unit is required to work with the Area Personnel Security/HR Office designee to maintain a list of staff members who have a favorably adjudicated background investigation with child care coverage on file for supervisors to identify and assign personnel to provide coverage to individuals in a provisional status.

I have verified that I have worked with the facility/service unit to ensure that a list of favorably adjudicated staff members is available for the supervisor’s use.

Personnel Security Representative/HR 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 disciplinary action, up to and including removal/termination.

Employee/Contractor/Affiliate Date

1 / 2018

Indian Health Service Office of Human Resources

This form may also be used to assess fitness for federal contract employment

Form Approved:

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

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

All your answers must be truthful and complete.

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

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

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

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

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

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

(Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

(Include city and state or country)

YES NO (If "NO", provide country of citizenship)

(MM / DD / YYYY)

(For example, maiden name, nickname, etc.) (Include area codes)

Day

Night

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

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

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

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

MM/DD/YYYY) MM/DD/YYYY)

The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

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

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.)

10. Have you been convicted by a military court-martial in the past 7 years?

11. Are you currently under charges for any violation of law?

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency?

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.)

YES NO

YES NO

YES NO

YES NO

YES NO

OMB No. 3206-0182

U.S. Office of Personnel Management 5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised October 2019

Previous editions obsolete and unusable

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, 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 half-sister.)

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

YES NO

YES NO

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed

If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith.

that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government.

that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? D

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

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

YES NO DO NOT KNOW

YES NO DO NOT KNOW

Enter Date of Appointment or Conversion

MM / DD / YYYY

OMB Approved Form No. 0917-0028 Expiration Date:

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.]

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

YES______ NO______

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

I certify that (1) my response to these questions is made under penalty of perjury, which is punishable by fine under title 18 of the U.S. Code, or imprisonment of not more than five years, or both; and (2) I have received notice that a criminal check will be conducted. I understand my right to obtain a copy of any criminal history report made available to the Indian Health Service and my right to challenge the accuracy and completeness of any information contained in the report.

Applicant’s Signature (sign in ink) Date

Public Burden Statement: In accordance with Paperwork Reduction Act [5 CFR § 1320.8 (b)(3)], a Federal agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Respondents must be informed (on the reporting instrument, in instructions, or in a cover letter) the reasons for which the information will be collected; the way the information will be used to further the proper performance of the functions of the agency;

whether responses to the collection of the information are voluntary, required to obtain a benefit (citing authority), or mandatory (citing authority); and the nature and extent of confidentiality to be provided, if any (citing authority). Public reporting burden for this collection of information is estimated to average 12 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection information. Send comments regarding the burden estimate or any other aspect of this collection of information to the IHS Information Collection Clearance Officer, Indian Health Service, Office of Management Services, Division of Regulatory Affairs, 5600 Fishers Lane, Rockville, Mail Stop 09E70, MD 20857. Please do not send completed data collection instruments to this address.

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. 52.204-7 System for Award Management October 2018

2. 52.204-9 Personal Identity Verification of Contractor January 2011 Personnel

3. 52.204-13 System for Award Management Maintenance October 2018

4. 52.204-16 Commercial and Government Entity Code August 2020 Reporting

5. 52.204-17 Ownership of Control of Offeror August 2020

6. 52.204-18 Commercial and Government Entity Code August 2020 Maintenance

7. 52.204-19 Incorporation by Reference of December 2014 Representations and Certifications

8. 52.212-1 Instructions to Offerors – Commercial Products September 2023 and Commercial Services

9. 52.212-4 Contract Terms and Conditions November 2023

- Commercial Products and Commercial Services

10. 52.224-1 Privacy Act Notification April 1984

11. 52.224-2 Privacy Act April 1984

12. 52.232-39 Unenforceability of Unauthorized Obligations June 2013

13. 52.232-40 Providing Accelerated Payments to Small March 2023 Business Subcontractors

14. 52.237-1 Site Visits April 1984

15. 52.237-2 Protection of Government Buildings April 1984 Equipment, and Vegetation

16. 52.237-7 Indemnification and Medical Liability Insurance January 1997

17. 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 November 2021

2. 52.212-3

3. 52.212-5

4. 52.217-8

5. 52.252-1

6. 52.252-2

Representation Regarding Certain Telecommunica ations nd Vide Suro veillance Sales Equipment

Offeror Representations and Certifications - Commercial Products and Commercial Services (See Attached)

Contract Terms & Conditions Required to Implement Statutes or Executive Orders – Commercial Products & Commercial Services (See Attached)

Option to Extend Services

Solicitation Provisions Incorporated by Reference

Clauses Incorporated by Reference

May 2024

May 2024

April 1984

February 1998

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—

(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);

(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)

52.217-8 Option to Extend Services.

As prescribed in 17.208(f), insert a clause substantially the same as the following:

OPTION TO EXTEND SERVICES (NOV 1999)

The Government may require continued performance of any services within the limits and at the rates specified in the contract. These rates may be adjusted only as a result of revisions to prevailing labor rates provided by the Secretary of Labor. The option provision may be exercised more than once, but the total extension of performance hereunder shall not exceed 6 months. The Contracting Officer may exercise the option by written notice to the Contractor within __30 days___ [insert the period of time within which the Contracting Officer may exercise the option].

(End of clause)

52.252-1 Solicitation Provisions Incorporated by Reference.

As prescribed in 52.107(a), insert the following provision:

SOLICITATION PROVISIONS INCORPORATED BY REFERENCE (FEB 1998)

This solicitation incorporates one or more solicitation provisions by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. The offeror is cautioned that the listed provisions may include blocks that must be completed by the offeror and submitted with its quotation or offer. In lieu of submitting the full text of those provisions, the offeror may identify the provision by paragraph identifier and provide the appropriate information with its quotation or offer. Also, the full text of a solicitation provision may be accessed electronically at this/these address(es): https://www.acquisition.gov

(End of provision)

52.252-2 Clauses Incorporated by Reference.

As prescribed in 52.107(b), insert the following clause:

CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es):

https://www.acquisition.gov

(End of Clause) III. Department of Health and Human Services Acquisition Regulations (HHSAR) (49

Chapter 3) Clauses

No. HHSAR Citation Clause Title Clause Date_ ____

1. HHSAR 352.224-70 Privacy Act December 2015

2. HHSAR 352.224-71 Confidential Information December 2015

3. HHSAR 352.232-71 Electronic Submission of Payment February 2022 Requests

4. HHSAR 352.237-70 Pro-Children Act December 201

5. HHSAR 352.237-71 Crime Control Act-Reporting of December 2015 Child Abuse

6. HHSAR 352.237-72 Crime Control Act-Requirement December 2015 For Background Checks

7. HHSAR 352.237-73 Indian Child Protection and December 2015 Family Violence Act

8. HHSAR 352.237-74 Non-Discrimination in Service Delivery December 2015

352.224-70 Privacy Act.

As prescribed in HHSAR 324.105(a), the Contracting Officer shall insert the following clause: Privacy Act (DEC 2015)

This contract requires the Contractor to perform one or more of the following: (a) Design; (b) develop;

or (c) operate a Federal agency system of records to accomplish an agency function in accordance with the Privacy Act of 1974 (Act) (5 U.S.C. 552a(m)(1)) and applicable agency regulations.

The term system of records means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual. Violations of the Act by the Contractor and/or its employees may result in the imposition of criminal penalties (5 U.S.C. 552a(i)).

The Contractor shall ensure that each of its employees knows the prescribed rules of conduct in 45 CFR part 5b and that each employee is aware that he/she is subject to criminal penalties for violation of the Act to the same extent as Department of Health and Human Services employees. These provisions also apply to all subcontracts the Contractor awards under this contract which require the design, development or operation of the designated system(s) of records (5 U.S.C. 552a(m)(1)). The contract work statement:

(a) Identifies the system(s) of records and the design, development, or operation work the Contractor is to perform; and

(b) Specifies the disposition to be made of such records upon completion of contract performance.

(End of clause)

352.224-71 Confidential Information.

As prescribed in HHSAR 324.105(b), insert the following clause:

Confidential Information (DEC 2015)

(a) Confidential Information, as used in this clause, means information or data of a personal nature about an individual, or proprietary information or data submitted by or pertaining to an institution or organization.

(b) Specific information or categories of information that the Government will furnish to the Contractor, or that the Contractor is expected to generate, which are confidential may be identified elsewhere in this contract. The Contracting Officer may modify this contract to identify Confidential Information from time to time during performance.

(c) Confidential Information or records shall not be disclosed by the Contractor until:

(1) Written advance notice of at least 45 days shall be provided to the Contracting Officer of the Contractor's intent to release findings of studies or research, to which an agency response may be appropriate to protect the public interest or that of the agency.

(2) For information provided by or on behalf of the government,

(i) The publication or dissemination of the following types of information are restricted under this contract: [INSERT RESTRICTED TYPES OF INFORMATION. IF NONE, SO STATE.]

(ii) The reason(s) for restricting the types of information identified in subparagraph (i) is/are: [STATE

WHY THE PUBLIC OR GOVERNMENT INTEREST REQUIRES THE RESTRICTION OF EACH

TYPE OF INFORMATION. ANY BASIS FOR NONDISCLOSURE WHICH WOULD BE VALID

UNDER THE FREEDOM OF INFORMATION ACT IS SUFFICIENT UNDER THIS CLAUSE.]

(iii) Written advance notice of at least 45 days shall be provided to the Contracting Officer of the Contractor's intent to disseminate or publish information identified in subparagraph (2)(i).