Section J Combined.pdf

Attachment J-1 https://smart.csosa.gov/Treatment/CORTApprovals/VRL_Letter.aspx?placementID=73583[9/19/2018 10:47:39 AM]

MEMORANDUM

To:

Court Services and Offender Supervision Agency Office of the Director

Community Justice Programs

Through:

Vendor CSOSA-

XX-XXXX

Program Manager

From: Arvetta Weston Treatment Management Program Analyst

Date: 9/10/2018

Subject: Billing Authorization

Enclosed please find a referral package for Offender who is in need of treatment. The duration of treatment for this offender shall not exceed 28 Days.

You are required to complete the attached admission confirmation form within 24 hours of the scheduled admission date. The admission confirmation must be faxed back to Arvetta Weston on (202) 220-5463.

Name PDID Number

Admission Date

Discharge Date Shall Not Exceed

Pick-Up Location/Time

Obligation/Invoice Shall Not Exceed

Solicitation No. 9594CS26Q0041

Attachment J-1 https://smart.csosa.gov/Treatment/CORTApprovals/VRL_Letter.aspx?placementID=73583[9/19/2018 10:47:39 AM]

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

Thank you.

FAX

To :

From :

Arvetta Weston, CSOSA Treatment Management Program Analyst

Vendor

CSOSA-XX-XX-XXX

Date :

Name PDID Vendor Treatment Status - Admitted? If no, indicate reason mailto:RPT@CSOSA.gov

Court Services and Offender Supervision Agency for the District of Columbia

CSOSA – Substance Abuse Treatment Revised 8/2008

RELEASE OF INFORMATION:

Substance Abuse Treatment

Name of Offender: __________________ DCDC No.__________ PDID No.__________ Date of Birth: ________

I hereby consent to one of the following :

Criminal Justice Consent: I consent to the release of the information noted below by ___________ to the authorized person(s) or organization recipient(s) noted directly below.

I understand that the information noted directly below may be disclosed to the judge presiding in my supervision case, the prosecutor, defense attorney, and CSOSA Community Supervision Services handling my case in Docket _________. I understand that this information may also be disclosed in open court. This means there is a possibility that those in the courtroom may hear this information.

The purpose of and need for this Criminal Justice Consent is to inform the criminal justice entities listed above of my attendance and progress in treatment. The information to be disclosed is limited to my diagnosis, my attendance or lack of attendance at treatment sessions, and my cooperation with the treatment program and prognosis.

I understand that this Criminal Justice Consent will remain effective and cannot be revoked by me until my involvement in the criminal justice system ends in Docket ___________.

General Consent: I consent to the release of the information noted below to the authorized person(s) or organization recipient(s) noted in the box below.

I understand that the information noted below may be released to inform the party named of my participation in drug and/or alcohol treatment as a condition of my release to the community. I understand that my participation in a substance abuse treatment program will be shared with the party named to inform the party of my efforts to remain clean and sober or for the purpose noted below.

I understand that this General Consent can be revoked by me at any time except to the extent a disclosure was already made in reliance on it, but if not revoked, it will remain in effect until ______________________________ [provide date or event upon which this consent expires].

Information to be disclosed:

Authorized Person or Organization Recipient for General Consent:

Purpose of Disclosure:

I also understand that any disclosure made as a result of this authorization is bound by Title 42, Code of Federal Regulations, Part 2, which governs the confidentiality of alcohol and other drug abuse patient records, and that the information may not be redisclosed without my express written consent.

Signature of Offender: ______________________ Witnessed by: ______________________

Date Signed: __________ Date Signed: __________

Attachment J-2 Solicitation No. 9594CS26Q0041

CSOSA - Health Revised 8/2008

RELEASE OF INFORMATION:

Health Records*

I, __________________________________________________________(Name of offender), hereby consent to the release of the information noted in the table below by _________________ to the authorized person(s) or organization recipient(s) noted in the table below.

In authorizing this disclosure of health information, I understand that the information will be used for the purpose noted in the table below, both now and for as long as my consent remains valid.

Nature of Information to be Disclosed:

Authorized Recipient (Person or Organization):

Purpose of Disclosure:

I understand that this information cannot be redisclosed by the person or organization who receives it without my authorization.

The unauthorized disclosure of HIV/AIDS or cancer information violates the provisions of the District of Columbia Official Code §§ 7-302 and 7-1605, which provide for the confidentiality of HIV/AIDS and cancer patient records. Any HIV/AIDS or cancer information may not be redisclosed by the recipient without my express written consent.

I understand that this consent may be revoked in writing by me at any time, and if not revoked, will expire on _________. I also understand that a copy of this waiver will be placed in my file.

Signature of Offender:

Date Signed:

Offender’s Date of Birth:

Offender’s DCDC Number:

Offender’s PDID Number:

Witnessed by:

Date Signed:

* Note that this form may NOT be used to authorize the disclosure of mental health information. The D.C. Mental Health Information Act requires the use of specific language to authorize the disclosure of such information. See the mental health consent form.

Attachment J-3 Solicitation No. 9594CS26Q0041

Court Services and Offender Supervision Agency for the District of Columbia

COMMUNITY SUPERVISION SERVICES

CONSENT FOR THE RELEASE OF SENSITIVE OFFENDER INFORMATION:

MENTAL HEALTH TREATMENT

OR

SEX OFFENDER TREATMENT

I, ___________________________________________, hereby consent to the release of the following information, (Name of offender)

(nature of information to be disclosed) by the Court Services and Offender Supervision Agency (CSOSA) to _______________________________________.

(authorized person or organization recipient)

In authorizing this disclosure of mental health information, I understand that the information will be used for the purpose of

_______________________________________________ , both now and in the future. I understand that I may permit

CSOSA to release information that it obtains after the date of this authorization for a period of up to 365 calendar days. If I do not state below when this authorization expires, then it will expire 365 calendar days from the date that I signed this form. I understand that this information cannot be disclosed by the person or organization who receives it without my authorization and that the law requires this notice:

The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978 (D.C. Official Code §§ 7-1201.01 – 7-1208.07). Disclosures may only be made pursuant to a valid authorization by the client or as provided in Titles III or IV that Act.

The Act provides for civil damages and criminal penalties for violations.

I understand that this consent may be revoked in writing by me except in connection with a life or health insurance policy under D.C. Official Code § 7-1202.02(a)(3). I also understand that I have a right to examine and review my mental health records. I understand that a copy of this waiver will be provided to me as well as the individual responsible for making the actual disclosure(s). I also understand that a copy of this waiver will be placed in my file.

Authorization for release of information expires on __________(date cannot exceed 365 calendar days from the date this form is signed).

Signature of Offender/Date Signed Witnessed By/Date Signed

Offender’s Date of Birth

Offender’s DCDC Number

Offender’s PDID Number

[CSOSA - MH/S.O.]

Attachment J-4 Solicitation No. 9594CS26Q0041

CSOSA-OGC-0005 Revision: August 2008

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 ______________, 201_.

Signature

Attachment J-5 Solicitation No. 9594CS26Q0041

Attachment J-6

Monthly Program Activity Report

Contractor Name: Contract Number:

Program Address:

Treatment Modality:

Submitted By: Telephone Number:

PERFORMANCE TARGETS

For the Month of Year

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

TABLE 1 (Non- RSC Cases)

A. Total Number of active cases at the end of the previous month

B. Total Scheduled Placements No Shows Actual Admissions

C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended

Total number of active cases at the end of the month

TABLE 2 (Non-RSC Cases):

Please include the names and PDID numbers of individuals for each category

ADMITTED NO-SHOWS SUCCESSFUL

COMPLETIONS

UNSUCCESSFUL

COMPLETIONS

(Please attach discharge reports for each name listed below)

TABLE 3 (RSC Cases)

A. Total Number of active cases at the end of the previous month

B. Total Scheduled Placements No Shows Actual Admissions

C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended

Total number of active cases at the end of the month

Attachment J-6

TABLE 4 (RSC Cases):

Please include the names and PDID numbers of individuals for each category

ADMITTED NO-SHOWS SUCCESSFUL

COMPLETIONS

UNSUCCESSFUL

COMPLETIONS

(Ple ase attach discharge re ports for each name liste d be low)

TABLE 5: Monthly CSOSA Contract Staff Changes

New Hires Name (Please attach the medical clearance, resumes, licenses and certifications)

Position Title Hire Date

Security Clearance Submission Date

Resignations or Terminations

Position Title Separation Date

Attachment J-6 Solicitation No. 9594CS26Q0041

TABLE 6: Unusual Incidents Please attach copies of all incident reports (via secured email method) to this monthly report.

A. Total Number of unusual incident reports for the month:

Date of incident

Date report was submitted to

CSOSA

B. Type(s) of unusual incidents for the month.

Death, serious illness, injury or incapacitation Physical, sexual or verbal abuse of an Patient by staff or others Fire Theft Destruction of loss of property, or sudden/serious problems in the facility Patient criminal charges, arrest, or incarceration Infestations or outbreak of communicable disease Inappropriate relationships/fraternization between an Patient and contract staff Chronic complaints from Patient’s families or Patients themselves

Monthly Physical Plant Issues (Provide narrative, describing all serious facility maintenance problems):

Solicitation No. 9594CS26Q0041Attachment J-6

CSOSA-SEC-0010 1 Revision: 11/2002 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-7 Solicitation No. 9594CS26Q0041

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

Solicitation No. 9594CS26Q0041Attachment J-7

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

Solicitation No. 9594CS26Q0041Attachment J-7

CSOSA-SEC-0008 Revision: 11/2002 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

Attachment J-8 Solicitation No. 9594CS26Q0041

Attachment J-9

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

Signature Printed Name

Solicitation 9594CS26Q0041 - Attachment J-10: Cover Letter A completed Attachment J-10: Cover Letter must be provided with any submitted proposal.

1. Full name of Offeror:

2. Full address of Offeror:

3. Offeror’s Point of Contact:

a. Name:

b. Phone number:

c. Email address:

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

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

6. A copy of the OF-308 and all Solicitation Amendments (OF309) (if issued), signed by an individual authorized to bind the Offeror, shall be provided following this Cover Letter.

7. The Offeror has reviewed the insurance requirements in the solicitation, section H.9 Insurance, and will provide the required Certificate of Insurance that meets or exceeds the requirements of Section H.9 within 10 days of award. (Note: A post-award request to have any H.9 Insurance requirements waived or reduced will not be considered.)

Signature of individual authorized to bind Offeror:

8. The pricing provided in the Price Proposal is good for 120 calendar days from the date of submittal. Signature of individual authorized to bind Offeror:

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

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

Signature of individual authorized to bind Offeror:

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

Cover Letter signature of individual authorized to bind Offeror:

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 proposal) 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.washington@csosa.gov no later than Friday, August 28, 2026, 3:00 PM (ET) 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 Number:594CS26Q0041 Attachment J- 11 Past Performance Questionnaire Page 2 of 4

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 Number: 9594CS26Q0041

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 Number: 9594CS26Q0041

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 Solicitation No.

9594CS26Q0041

Base Period: Date TBD at Award Item No. Schedule of Supplies/Services Quantity Unit Unit Price Amount

0001 Low Intensity Residential Treatment Services

7,300 Day $ $

Total Base Period Not to Exceed Price $

Option Period 1: Date TBD at Award Item No. Schedule of Supplies/Services Quantity Unit Unit Price Amount

1001 Low Intensity Residential Treatment Services

7,300 Day $ $

Total Option Period 1 Not to Exceed Price $

Option Period 2: Date TBD at Award Item No. Schedule of Supplies/Services Quantity Unit Unit Price Amount

2001 Low Intensity Residential Treatment Services

7,300 Day $ $

Total Option Period 2 Not to Exceed Price $

Option Period 3: Date TBD at Award Item No. Schedule of Supplies/Services Quantity Unit Unit Price Amount

3001 Low Intensity Residential Treatment Services

7,300 Day $ $

Total Option Period 3 Not to Exceed Price $

Option Period 4: Date TBD at Award Item No. Schedule of Supplies/Services Quantity Unit Unit Price Amount

Low Intensity Residential Treatment Services 7,300 Day $ $

Total Option Period 4 Not to Exceed Price $

Attachment J-12 – Pricing Tables Solicitation No.

9594CS26Q0041

FAR 52.217-8 Option: 6 months from the effective date of Option Period 5

Item No.

Schedule of Supplies/Services Quantity Unit Unit Price Amount

Low Intensity Residential Treatment Services 4,380 Day $ $

Total FAR 52.217-8 Option Period Not to Exceed Price $

Total Base and All Option Periods Not to Exceed Price $ _ _ _ _ _ _

LowIntensity_Attachment J-13 Pricing Table