Section J COMBINED.pdf

MEMORANDUM

To:

Through:

From:

Date:

Subject:

Enclosed please find a referral package for who is in need of treatment. The duration of treatment for this offender shall not exceed the sessions as outlined in the chart below.

You are required to complete the attached admission confirmation form within 24 hours of the scheduled admission date. The admission confirmation must be emailed back to THPT@CSOSA.gov

Program Units Admission Date

Discharge Date Shall Not Exceed

Pick-Up Location/Time

Obligation/Invoice Shall Not Exceed

633 Indiana Avenue, NW, Washington, DC 20004 | P (202) 220-5300 | F (202) 220-5350

Attachment J-1 Solictation #9594CS26Q0057

No later than 24 hours after the scheduled pick-up, please email this form back to THPT@CSOSA.gov and indicate reasons for non-admission.

Thank you.

To :

From :

Date :

Name PDID Vendor Program Treatment Status - Admitted? If no, indicate reason

633 Indiana Avenue, NW, Washington, DC 20004 | P (202) 220-5300 | F (202) 220-5350

Attachment J-1 Solicitation No. 9594CS26Q0057

[THIRD PARTY GENERAL]

Solicitation 9594CS26Q0057 – Attachment J-2

Court Services and Offender Supervision Agency for the District of Columbia

COMMUNITY SUPERVISION SERVICES

AUTHORIZATION FOR RELEASE OF INFORMATION AND WAIVER:

GENERAL THIRD PARTY DISCLOSURE

I, , hereby consent to the disclosure of information (Name of Offender) specified below between the Court Services and Offender Supervision Agency for the District of Columbia and

(Name of Third Party)

The purpose of and need for the disclosure is to inform the party named above of coordinate treatment services (Purpose of Disclosure)

The information to be disclosed is limited to the following:

Substance Abuse Treatment (authorizes sharing of CSOSA drug test results), Medical Records (PPD/TST, X-Ray results), Mental Health/Sex Offender Information, medications and medical conditions (diagnoses and recommendations)

(Information to be Disclosed)

I understand that this consent will remain effective until it is revoked by me, or until .

(Enter Date)

I also understand that a redisclosure of this information may not be made without my express written authorization.

Signature of Offender/ Date Signed Witnessed By/Date Signed

Offender’s Date of Birth

Offender’s DCDC Number

Offender’s PDID Number

Print Form Reset Form

Signature

CSOSA-OGC-0005 Revision: August 2008

Print Form Reset Form

Solicitation 9594CS26Q0057 – Attachment J-3

Court Services and Offender Supervision Agency for the District of Columbia

Attachment J-1:RELEASE OF

INFORMATION PRIVACY ACT WAIVER

I, [Name], hereby authorize and give my prior written consent pursuant to 5 U.S.C. § 552a(b) to the

Court Services and Offender Supervision Agency for the District of Columbia, to disclose the information noted below concerning me to the recipient(s) noted below for the purpose noted below.

Information to be disclosed:

Recipient(s):

Purpose of disclosure:

I declare under penalty of perjury that the foregoing is true and correct.

Executed this day of , 202_.

633 INDIANA AVENUE, NW, WASHINGTON, DC 20004 | P (202) 220-5300 | F (202) 220-5350

No-Show/Missed Appt. Monthly Report

Re p or t in g Mon t h : ___________________________ Progra m / De p a r t m e n t : _____________________ Pre p a re d By: ______________________________ Da t e Pr e p a re d : _____________________________ This report sum m arize s m issed assessm ent appoin tm ents (no-shows) for the reporting pe riod . The purpose is to m onitor a ttend ance trends, asse ss ope ra tiona l im p act, and id en tify opportun itie s to red uce m issed appoin tm ents and im prove se rvice access.

1. Total Scheduled Assessments: _____

2. Total Completed Assessments: ______

3. Total Missed Assessments (No-Shows): ______

4. Same-Day Cancellations: __________

5. Overall No-Show Rate: ______ %

Summary Comments:

Appointment Attendance Overview

Appointment Status Number Scheduled

Referral Completed/Closed

No-Shows

Same-Day Cancellations Rescheduled during this reporting period

Attachment J-4

Solicitation No.9594CS26Q0057

No-Show Analysis

Weekly Breakdown

Week Scheduled No-Shows No-Show Rate Week 1 Week 2 Week 3 Week 4

Reasons for No-Shows

Reason Number of Occurrences

No Call / No Show Client Forgot Appointment Transportation Issues Illness / Emergency Scheduling Error Other / Unknown

Follow-Up Actions Taken

☐ CSO & Client contacted for rescheduling ☐ Appointment reminders reviewed ☐ Case notes updated

☐ Referred to community Based Organization ☐ No-show policy applied ☐ Referral, discharge, or escalation considered

Action Summary:

Review and Approval

Reviewed By: _______________________________ Title: ______________________________________ Signature: __________________________________ Date: ______________________________________

Attachment J-4

Solicitation No. 9594CS26Q0057

Solicitation 9594CS26Q0057 – Attachment J-5

Monthly Program Activity Report

Contractor Name: Contract Number:

Program Address:

Treatment Modality: Individual & Group Therapy; Case Consultation

Submitted By: Telephone Number:

PERFORMANCE TARGETS

For the Month of Year

Instructions: Please complete the numbers and names required for the tables below. Attach additional pages if necessary.

TABLE 1 Group Therapy

Description of Counseling Services # of Supervisees

A. Total Number of cases referred this month

B. Total Scheduled Placements (assigned to groups) Actual Assignments (Started) Denied/Not Eligible

C. Total Discharges #Successful completion of groups #Unsuccessful Completions of groups

Discharge for non-compliance Dropout against clinical advice Rearrested/remanded Medical/hospitalized Administrative

Supervision period ended

Total number of active cases at the end of the month

TABLE 2 Individual Therapy

Description of Counseling Services # of Supervisees A. Total Number of active cases referred this month

B. Total Scheduled Placements (assigned to therapists) Actual Admissions (started) Denied/Not Eligible

C. Total Discharges Successful Completion of all sessions Unsuccessful Completions Discharge for non-compliance Dropout against clinical advice Rearrested/remanded Medical/hospitalized Administrative Supervision period ended

Total number of active cases at the end of the month

TABLE 3 CASE CONSULTATIONS

SUPERVISEE

NAME

PDID# Reason for Consultation

OUTCOME OF

CONSULTATION

Solicitation 9594CS26Q0057 – Attachment J-5

633 INDIANA AVENUE, NW, WASHINGTON, DC 20004 | P (202) 220-5300 | F (202) 220-5350

Translation Services - Monthly Report Contract Number: __________________________________________ Reporting Period: ___________________________________________ Contractor: ________________________________________________ Prepared by:_______________________________________________] Submission Date: ___________________________________________

Summary of Services

Services Provided

• Virtual: _____________ In-person: ____________________

• Languages Supported:

• Type of Services:

o ______________________________________ o ______________________________________ o ______________________________________

• Materials Supported: (translating documents, forms, reports, presentations, and testing instruments)

Service Volume

• Total translation requests completed: _____________________________________

• Total interpretation hours provided: ______________________________________

• Total pages/words translated (if applicable): _______________________________

Issues or Challenges

Certification

I certify that this report accurately reflects the services provided during the reporting period.

Authorized Signature: ________________________ Name / Title: ______________________________ Date: ____________________________________

Attachment J-6

Court Services and Offender Supervision Agency for the District of Columbia

MEMORANDUM

This is a release for the Court Services and Offender Supervision Agency to obtain one or more consumer/credit reports about you in connection with your application for employment or in the course of your employment with the Court Services and Offender Supervision Agency. One or more reports about you may be obtained for employment purposes, including evaluating your fitness for employment, promotion, reassignment, retention, or access to classified information.

I,______________________________________, hereby authorize the Court Services and

Offender Supervision Agency to obtain such report(s) from any consumer/credit reporting agency for employment purposes.

Signature

Date

Social Security Number

CSOSA-SEC-0008 Revision: 11/2002

Attachment J-7 Solicitation No. 9594CS26Q0057

CSOSA-SEC-0010 1 Revision: 10/2013

Court Services and Offender Supervision Agency for the District of Columbia

SECURITY FORM FOR TEMPORARY CONTRACTORS

This form is to be used for all contractor personnel performing work under contract with CSOSA. It is to be completed as indicated and returned to the Office of Security by the Contracting Officer. Upon receipt of the completed documentation, the Office of Security will conduct a CSOSA background check and will notify the CO when the individual is approved to begin work.

PART I – TO BE COMPLETED BY THE CONTRACTING OFFICER (CO) OR

CONTRACTING OFFICER REPRESENTATIVE (COR)

COR Program Office: ______________________ Tel: __________ Date: ________

� COR: __________________________________________

� Position Sensitivity: ______________________________________

� Desired Performance Start Date: ____________________________

� Contractor Name:__________________________________

Contract Number:__________________________________

Applicant Name:__________________________________

� Position Title: __________________________________________

� Position Description: __________________________________________

� Duration of Assignment: __________________________________

� NCIC/WALES Access: � Yes � No

� CSOSA Network Access: � Yes � No

Prepared By: ________________________ _______________________________ Print Name Signature & Date

Attachment J-8 Solicitation No. 9594CS26Q0057

PART II – TO BE COMPLETED BY THE APPLICANT

1. Full Name (Last, First, MI)__________________________________________________

2. Other Names Used (Maiden and Alias) ________________________________________

3. Telephone Number(s) where you can be reached ________________________________

4. Home Address (Street, City, State, and Zip Code)__________________________________

5. E-mail Address ______________________________________________________________

6. Sex Male Female

7. Race: __________________

8. Date of Birth (Mo/Day/Year)________________________________________________

9. Place of Birth (City, State, Country) __________________________________________

10. Social Security Number ____________________________________________________

11. U.S. Citizenship By Birth Naturalized Other

Attachment J-8

12. In the last seven years, have you been fired from a job, quit after being told you would be fired, or left by mutual agreement following allegations of misconduct or unsatisfactory performance?

Yes No If your answer is “Yes,” explain below:

Date Reason Employer’s Name & Address

13. In the last seven years, have you been arrested for, charged with, or convicted of any offense(s)? (Leave out traffic fines of less than $150).

Yes No If your answer is “Yes,” explain below:

Date Charge Police Agency Disposition

I certify that the statements made by me on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that this information will be used to conduct records checks for the purpose of either paid or unpaid employment with the Court Services and Offender Supervision Agency.

Signature Date

Attachment J-8

Court Services and Offender Supervision Agency Personal Identity Verification (PIV) Request Form

Upon Completion, return this form to the Registrar

Section I. PIV Request & Source Documentation (To be completed by Sponsor)

1. New Card? � Yes � No Replacement Card? � Yes � No 1a. Reason for Replacement____________________________________

Applicant Information Type � Employee � Contractor � Guest/Other

2. Name (Last, First, Middle): ________________________________________

3. Applicant ID Number (or SSN):________________________

4. DOB/POB:_________________________________________________

5. Organization/Title:___________________________________________________

6. Work Phone:_______________________________

I agree to sponsor the above Applicant for a PIV card and certify that all information provided is accurate to the best of my knowledge.

7. Sponsor / Enrollment Official Signature: ______________________________________________ 8. Date: ________________________

9. Sponsor/Enrollment Official printed Name and Telephone Number: _____________________________________________________

Section II. Card Approval and Identity Proofing (To be completed by Registrar)

10. NAC / Background Investigation / FBI Fingerprint Check Result (Circle one)

Favorable? � Yes � No (If no, notify Sponsor for adjudication decision)

11 Comments___________________________________________________

Card issuance � Approved � Disapproved

12. Access Level:: ____________________________________________________

13. Did Applicant present two forms of identification, one of which was a photo ID issued by a state or the Federal Government?

� Yes � No

14. Copies of Source Documents attached? � Yes � No

I certify that the above applicant appeared before me and presented two ID source documents in compliance with HSPD-12, which appeared to be genuine.

15. Registrar Signature: ________________________________________ 16. Date:____________________________

Section III. Card Details (To be completed by the Issuer, after Section II is completed)

17. Name on Card Is the Same as Name Above � Yes � No

18. PIV Card Number______________________________________________

19. Card expiration date:____________________________________________

A PIV card was issued to the Applicant identified above base on verification of the Applicant’s identity and the above Registrar’s approval.

At time of issue, applicant presented one photo ID, issued by a state or the Federal Government.

20. Issuer Official Signature: ________________________________________ 21. Date:____________________________

Section IV. Applicant Acknowledgement (To be completed by the Applicant, after Section III is completed) I confirm receipt of the PIV card identified above, verify that the information is accurate to the best of my knowledge, and agree to abide by all rules and responsibilities associated with this card as follows:

A. SAFEGUARDING: I accept responsibility for safeguarding the proximity/identification card issued to me. When I am not wearing the card or the card is not in my physical custody, I will secure it against loss or theft in the same or similar manner, as I would protect my purse or wallet against loss or theft.

B. USE: I will use the card for official purposes only and will not loan, give, or otherwise allow any other person to use my card for any purpose. I will use the card only for official identification.

C. COUNTERFEITING: I will not attempt to clone, modify, or obtain data from any proximity/identification card D. WEARING/DISPLAYING: When required, I will prominently display the front (photo side) of the card at all times within the workplace, and elsewhere as required. When displaying the card, it will be worn between the neck and waist, on the front of the wearer.

E. REPORTING LOSS OR THEFT: I will immediately report any loss or theft of the card to the Office of Security, Room 820, 633 Indiana Avenue (Tel: 220-5750). If I subsequently recover my lost or stolen card, I will promptly return it to the Security Staff.

F. RETURN OF CARD: I will immediately return the card to the Security Staff when my employment with the CSOSA or PSA is terminated, or upon a request by the appropriate authority.

22. Applicant Signature: _______________________________________________________ 23. Date:____________________________

Procurement Use Only (Fill Out Below Information) Contract Expiration Date: _________________________

Contract/Purchase Order No._______________________

Name (Printed)__________________________________

Signature____________________________________

Issuer Information Issuer Org/Phone Office of Security/220-5750

Name (Printed)__________________________________

Registrar Information Security Org/Phone Office of Security/220-5750

Name (Printed)__________________________________

Attachment J-9 Solicitation No. 9594CS26Q0057

Attachment J-10

CONTRACTOR CONFIDENTIALITY AND NONDISCLOSURE AGREEMENT

FOR

Insert Contract Number and Title

This NONDISCLOSURE AGREEMENT (this “Agreement”) is made and entered into as of _________ , 2025 by and between the Court Services and Offender Supervision Agency (“CSOSA” or “Agency”) and ______________________________________(“Contractor”).

1. “Confidential Information” means all information disclosed by CSOSA to Contractor at any time, either directly or indirectly in writing, orally or by inspection of tangible objects, that arises from or in any way relates or pertains to CSOSA or its business including, without limitation, all information generated by Contractor, whether alone or through or in conjunction with third parties, based in whole or in part on such information. Confidential Information may also include but may not be limited to: information disclosed to Contractor by Agency employee(s) or third parties and all information covered by the Federal Privacy Act, 5 U.S.C. §552a, including D.C.

Youth Records Confidentiality law, the D.C. Mental Health Act (D.C. Official Code§§ 7-

1201.01 et seq. (2001 Edition)), the D.C. HIV/AIDS statute (D.C. Official Code§§ 7-302 and 7- 1605 (2002 Edition)), drug/alcohol treatment records (42 C.F.R. Part 2); Freedom of Information Act (FOIA) (and D.C. FOIA (District of Columbia participants only). These Acts regulate the collection, maintenance, use and disclosure of personal and sensitive information by local and federal executive branch agencies such as CSOSA.

Confidential Information shall not, however, include any information which the Contractor can establish: (i) is or becomes publicly known and made generally available in the public domain through no action or inaction of Contractor; (ii) is already rightfully in the possession of the Contractor prior to the commencement of his/her employ and at the time of disclosure, as shown by Contractor through direct evidence immediately prior to the time of disclosure; (iii) is obtained by Contractor from a third party without a breach of such third party’s obligations of confidentiality; (iv) is independently developed by Contractor without use of or reference to CSOSA’s Confidential Information, as shown by documents and other competent evidence in Contractor’s possession; or (v) is required to be disclosed by a subpoena or order issued by a court of competent jurisdiction, provided that Contractor gives CSOSA prompt written notice of such requirement prior to such disclosure and assistance in obtaining an order protecting the information from public disclosure.

2. Limitations on Use and Disclosure. Contractor agrees not to duplicate or use any Confidential Information for any purpose except in furtherance of providing services to CSOSA.

Contractor agrees that he or she shall take all measures necessary to protect the secrecy of, and to avoid disclosure and unauthorized use of, the Confidential Information. Without limiting the foregoing, Contractor shall take at least those measures that Contractor takes to protect his or her own most highly confidential information. Contractor shall immediately notify CSOSA in the event of any unauthorized use or disclosure of the Confidential Information. Contractor shall not reverse engineer, disassemble or decompile any software or other tangible objects which embody CSOSA’s Confidential Information.

3. Copies. Contractor shall not make any copies of Confidential Information unless the same are previously approved in writing by the Office of the Director of CSOSA, Office of General Counsel, or expressly permitted hereunder. Contractor shall reproduce CSOSA’s proprietary rights notices on any such approved copies, in the same manner in which such notices were set forth in or on the original.

4. Video/Audio Recording. At no time shall Contractor videotape or audio record, any session, conversation or activity with an offender without written consent from the Office of the Director and the Office of the General Counsel. Any Podcasts developed throughout the duration of the contract is the sole and exclusive property of CSOSA.

5. No Obligation. Nothing herein shall obligate CSOSA or Contractor to proceed with or continue any transaction between them after the end of the contract period.

6. Return of Materials. All documents and other tangible objects (to include notes, pictures, audio tapes) containing or representing Confidential Information and all copies thereof which are in the possession of Contractor shall be and remain the property of CSOSA and shall be promptly returned to CSOSA upon CSOSA’s request.

7. No Rights. Nothing in this Agreement is intended to grant any rights to Contractor under any copyright of CSOSA materials, nor shall this Agreement grant Contractor any rights in or to Confidential Information except as expressly set forth herein.

8. Term. This Agreement shall survive until such time as all the Confidential Information becomes publicly known and made generally available through no action or inaction of Contractor.

9. Assignment. This Agreement shall bind and inure to the benefit of the parties hereto and their successors and assigns. This Agreement shall immediately and automatically transfer, and all rights, duties and obligations of CSOSA shall be fully assigned, to any successor CSOSA entity, effective on the date of formation, automatically and without the need for further documentation.

Further, CSOSA may assign this Agreement upon notice to Contractor, but without the need for consent.

10. Entire Agreement. This Agreement contains the entire agreement between the parties with respect to the subject matter hereof. Except as otherwise expressly agreed in writing, this Agreement controls over any other agreement or provision relating to the subject matter hereof, regardless of whether such agreement was entered into before, after or contemporaneously with this Agreement.

11. Governing Law; Venue. This Agreement shall be governed by the laws of the Federal Government, without reference to conflict of laws principles. Any dispute brought by Contractor must be brought in the federal court located in the District of Columbia, and each party hereby consents to the personal jurisdiction thereof.

13. Waiver; Amendment. Any failure to enforce any provision of this Agreement shall not constitute a waiver thereof or of any other provision hereof. This Agreement may not be amended, nor any obligation waived, except by a writing signed by both parties hereto.

14. These provisions are consistent with and do not supersede, conflict with, or otherwise alter the Contractor obligations, rights, or liabilities created by existing statute or Executive Order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or

(4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive Orders and statutory provisions are incorporated into this agreement and are controlling.

Each of the undersigned individuals represents and warrants that he/ she has read and agrees to be bound by the terms of this Agreement.

Contractor Name (print) Signature

Company Name Date

Attachment J-11 Past Performance Questionnaire When filled in, this document is Source Selection Sensitive Information

IAW FAR 2.101 and 3.104.

1. The Court Services and Offender Supervision Agency (CSOSA) is conducting an acquisition to provide Psychological Assessment Services for the CSOSA Office of Behavioral Intervention.

2. You have been listed by (enter name of entity submitting a quote) as a current or past client reference who can serve as a past performance reference. The following information is being collected to help the CSOSA Contracting Officer evaluate past performance during the evaluation of proposals.

3. The survey should be completed by the individual most knowledgeable of the Contractor’s day-to-day operations and overall condition of services being rendered. That individual is encouraged to supplement their own knowledge of the Contractor’s performance with the judgment of others in their organization, as applicable.

4. Handwritten responses are sufficient. Please make them legible.

5. Please provide explanatory narratives for as many responses as possible. These narratives need not be lengthy, just descriptive. Space for narrative comments is included on the last page of the survey. If more space is needed, additional pages may be added.

6. As the survey relates to an ongoing source selection for the services for above identified requirement, we request that all information provided within the survey be safeguarded against unauthorized disclosure.

7. Upon completion of the questionnaire, please e-mail it to RoShawn K. Washington at roshawn.washingtion@csosa.gov no later than Friday, August 14, 2026, 3:00 PM (EDT) ****************************************************************************** Date of Survey:

Name of Person Completing Survey:

Title of the Person Completing Survey:

Telephone and Fax Number:

Email Address:

Your Company/Agency:

Contract Name:

Contract Number:

Period of Contract Performance:

Total Dollar Amount of Contract:

Your Role in this Contract:

General description of products/services required under the contract:

6. Did the contractor perform as a prime or subcontractor?

7. Performance Information. Choose the number on the scale of 1 to 6 that most accurately describes the contractor’s performance or situation. Please provide a narrative explanation for any ratings of 1, 2 or 3.

mailto:roshawn.washingtion@csosa.gov

Solicitation No:594CS26Q0057

Evaluation Ratings Rating Definition

1 Neutral Performance was not observed or not applicable to the current effort being reported against.

2 Unsatisfactory Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance of the element or sub- element contains a serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

3 Marginal Performance does not meet some contractual requirements. The contractual performance of the element or sub- element being assessed reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

4 Satisfactory Performance meets contractual requirements. The contractual performance of the element or sub-element contains some minor problems for which corrective actions taken by the contractor were satisfactory.

5 Good Performance meets contractual requirements with some exceeded to the Government’s benefit. The contractual performance of the element or sub- element being assessed was accomplished with no more than some minor problems for which corrective actions taken by the contractor were effective.

6 Exceptional Performance meets contractual requirements with many exceeded to the Government’s benefit. The contractual performance of the element or sub- element being assessed was accomplished with no more than a few minor problems for which corrective actions taken by the contractor were highly effective.

Place an “X” in the appropriate block using the definitions matrix above.

SCHEDULE

1. Contractor’s responsiveness/timeliness in providing the required services. 1 2 3 4 5 6

2. Contractor’s responsiveness/timeliness to administrative functions of the contract.

1 2 3 4 5 6

3. Contractor’s responsiveness/timeliness in responding to questions or correspondence.

1 2 3 4 5 6

4. Contractor’s compliance with contract terms and conditions. 1 2 3 4 5 6

5. Were any contract concessions/changes/terminations made due to the contractor’s failure to accurately plan?

Yes No

MANAGEMENT OF KEY PERSONNEL

6. Demonstrated ability to hire, maintain, and replace, if necessary, qualified personnel during the contract period.

1 2 3 4 5 6

7. Contractor’s preparation & training of personnel. 1 2 3 4 5 6

8. Contractor’s ability to effectively manage subordinates. 1 2 3 4 5 6

Solicitation No: 9594CS26Q0057

QUALITY OF SERVICES

9. Provided effective quality control and/or inspection procedures to meet contract requirements.

1 2 3 4 5 6

10. Followed approved quality control plan. 1 2 3 4 5 6

11. Corrected deficiencies in timely manner and pursuant to their quality control procedures.

1 2 3 4 5 6

12. Provided timely resolution of contract discrepancies. 1 2 3 4 5 6

13. Identified problems as they occurred. 1 2 3 4 5 6

14. Suggested alternative approaches to problems. 1 2 3 4 5 6

15. Displayed initiative to solve problems. 1 2 3 4 5 6

16. Developed realistic progress schedules. 1 2 3 4 5 6

17. Met established project schedules. 1 2 3 4 5 6

18. Contractor’s ability to assimilate & accommodate changes in contractual requirements and/or priority.

1 2 3 4 5 6

19. Contractor’s exhibited knowledge of and compliance with Government (or other) regulations.

1 2 3 4 5 6

20. Contractor’s demonstration of technical expertise in providing all contractual services.

1 2 3 4 5 6

21. Contractor possession/utilization of tools/equipment necessary for adequately providing the required services.

1 2 3 4 5 6

22. Contractor’s accomplishment in meeting the Quality standards specified for:

a. Technical Performance 1 2 3 4 5 6

b. Administrative Performance 1 2 3 4 5 6

23. Has the Contractor ever failed to effectively control the quality of services provided? If yes, please explain in Remarks Section.

Yes No

24. Has a Contract Discrepancy Report (or equivalent) ever been issued? If yes, please explain in the Remarks Section.

Yes No

25. Has a Cure Notice or Show Cause Letter ever been issued? If yes, please explain in the Remarks Section.

Yes No

26. Have there been any disputes/claims relative to the contract? If yes, please explain in the Remarks Section

Yes No

Solicitation No: 9594CS26Q0057

27. Has a Contractor demonstrated the ability to correct any of the problems referenced above? If yes, please explain in the Remarks Section.

Yes No

28. Has a Contract been terminated for default? If yes, please explain in the Remarks Section.

Yes No

29. Has an election ever been made to not exercise an option due to the Contractor’s poor performance? If yes, please explain in the Remarks Section

Yes No

25. Has a Cure Notice or Show Cause Letter ever been issued? If yes, please explain in the Remarks Section.

Yes No

26. Have there been any disputes/claims relative to the contract? If yes, please explain in the Remarks Section

Yes No

27. Has a Contractor demonstrated the ability to correct any of the problems referenced above? If yes, please explain in the Remarks Section.

Yes No

28. Has a Contract been terminated for default? If yes, please explain in the Remarks Section.

Yes No

29. Has an election ever been made to not exercise an option due to the Contractor’s poor performance? If yes, please explain in the Remarks Section

Yes No

BUSINESS RELATIONS

30. Contractor’s management of subcontracts. 1 2 3 4 5 6

31. Have there been any labor disputes? If yes, please explain in the Remarks Section.

Yes No

32. Have there been any violations of Public Law, especially the Service Contract Act? If yes, please explain in the Remarks Section.

Yes No

33. Contractor’s ability/willingness to consistently provide prompt and courteous service.

1 2 3 4 5 6

34. Contractor’s ability/willingness to promptly and courteously resolve customer complaints.

1 2 3 4 5 6

35. Contractor’s overall commitment to customer satisfaction. 1 2 3 4 5 6

37. How would you rate the integration and coordination of all activity needed to perform this contract?

1 2 3 4 5 6

38. How would you the Contractor’s overall performance? 1 2 3 4 5 6

39. Would you award another contract to this Contractor? If not, please explain in the Remarks Section.

Yes No

Remarks:

Attachment J-12 – Pricing Tables

Tables: Breakdown of Services in CLINs 0001, 1001, 2001, 3001, and 4001

Line Item

OPTION TWO (12 MONS)

Description of Services Quantity Unit Unit

Price Not-to-Exceed Amount

1001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours

Translation Services ** 10 Hours

Tables: Breakdown of Services in CLINs 0001, 1001, 2001, 3001, and 4001

Line Item

BASE (12 MONS)

Description of Services Quantity Unit Unit

Price Not-to-Exceed Amount

0001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours

Translation Services ** 10 Hours

Line Item

OPTION ONE (12 MONS)

Description of Services Quantity Unit

Unit Price

Not-to-Exceed Amount

2001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours Translation Services ** 10 Hours

Attachment J-12 – Pricing Tables

Total Purchase Order Not to Exceed/Ceiling $_____________

** The quoter is required to provide a single unit price for any translation services regardless of the type.

Tables: Breakdown of Services in CLINs 0001, 1001, 2001, 3001, and 4001

Line Item

OPTION THREE (12 MONS)

Description of Services Quantity Unit Unit

Price Not-to-Exceed Amount

3001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours Translation Services ** 10 Hours

Tables: Breakdown of Services in CLINs 0001, 1001, 2001, 3001, and 4001

Line Item

OPTION FOUR (12 MONS)

Description of Services Quantity Unit Unit

Price Not-to-Exceed Amount

4001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours Translation Services ** 10 Hours

Tables: Breakdown of Services in CLINs 0001, 1001, 2001, 3001, and 4001

Line Item

FAR 52.217-8 Option ( 6 MONS)

Description of Services Quantity Unit

Unit Price Not-to-Exceed

Amount

5001 Psychotherapy and Counseling Services 1 Lot

Group Sessions 683 Hours Individual Sessions 200 Hours Case Consultations 47 Hours Translation Services ** 10 Hours

Signature Printed Name

Solicitation 9594CS26Q0057 - Attachment J-13: Cover Letter A completed Attachment J-13: Cover Letter must be provided with any submitted quote.

1. Full name of Quoter:

2. Full address of Quoter:

3. Quoter’s Point of Contact:

a. Name:

b. Phone number:

c. Email address:

4. Quoter’s Tax identification number (TIN):

5. Quoter’s System for Award Management (SAM) Unique Entity Identification (UEI) Number:

6. Business Size for NAICS 621330: Offices of Mental Health Practitioners (except Physicians) (This should be the business size identified in the Quoter’s SAM registration for this NAICS, e.g., large business, small business, SDVOSB, etc.) If Quoter’s Representations and Certifications posted in SAM under FAR 52.219-1 does not include this NAICS code, this NAICS code should be added to the Quoter’s SAM registration prior to the submission of a quote. Failure to include the appropriate NAICS code [621330] under SAM registration prior to quote submitted due date and time will result in the applicable quotation deemed as non-responsive.

7. A copy of the SF1449 and all Solicitation Amendments (SF30) (if issued), signed by an individual authorized to bind the Quoter, shall be provided following this Cover Letter.

8. The Quoter has reviewed the insurance requirements in the solicitation, section H.14 Insurance, and will provide the required Certificate of Insurance that meets or exceeds the requirements of Section H.14 within 10 days of purchase order award. (Note: A post-award request to have any H.14 Insurance requirements waived or reduced will not be considered.)

Signature of individual authorized to bind Quoter:

9. The pricing provided in the Pricing Quotation is good for 120 calendar days from the date of submittal.

Signature of individual authorized to bind Quoter:

10. Any assumptions, exceptions, or conditions the Quoter makes, or takes, in their submission shall be provided as a separate attachment following this Cover Letter.

11. By signing this cover letter below, Offerors acknowledges receipt of any and all amendments applicable to this solicitation.

Signature of individual authorized to bind Quoter:

12. By signing below, an official authorized to bind your organization is stipulating its quotation is predicated upon all the terms and conditions of this RFQ.

Cover Letter signature of individual authorized to bind Quoter:

Attachment J-13 Pricing Table