Sol_75H71026Q00166.pdf

SEE ADDENDUMIS CHECKED

CODE 18a. PAYMENT WILL BE MADE BY

CODE

FACILITYCODE

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

OFFEROR

51CODE 16. ADMINISTERED BYCODE

X

X

337214

SIZE STANDARD:

% FOR:SET ASIDE:UNRESTRICTED OR51

REQUEST FOR

PROPOSAL

(RFP)

INVITATION

FOR BID (IFB)

10. THIS ACQUISITION ISCODE

REQUEST FOR

QUOTE (RFQ)

14. METHOD OF SOLICITATION

13b. RATING

NORTH AMERICAN INDUSTRY

CLASSIFICATION STANDARD

(NAICS):

SMALL BUSINESS

05/27/2026 1300 MT

05/20/2026

505-930-1975MELISSA LAKE

(No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBER a. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

75H71026Q00166

5. SOLICITATION NUMBER

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF

1 46 IHS1519246OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

TELEPHONE NO.

17a. CONTRACTOR/

15. DELIVER TO

Gallup NM 87301

1808 W. Aztec Avenue

Acquisition Department

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

ISSUE DATE

DELIVERY FOR FREE ON BOARD

(FOB) DESTINATION UNLESS

BLOCK IS MARKED

11.

SEE SCHEDULEX

12. DISCOUNT TERMS THIS CONTRACT IS A RATED

ORDER UNDER THE DEFENSE

PRIORITIES AND ALLOCATIONS

SYSTEM - DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

(SDVOSB)

HUBZONE SMALL

BUSINESS

8(A)

Gallup Indian Medical Center WOMEN-OWNED SMALL

BUSINESS (WOSB)

ECONOMICALLY DISADVANTAGED

WOMEN-OWNED SMALL

BUSINESS (EDWOSB)

Tohatchi NM 87325

07 Choosghai Drive

Tohatchi Health Center

Gallup NM 87301

1808 W. Aztec Avenue

Acquisition Department

Gallup Indian Medical Center

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

**This is an Indian-Owned Small Business Economic Enterprise (ISBEE) set-aside**

This contract is subject to the electronic payment process by the Department of Treasury.

All invoices complying to the requirements at 52.212-4(g) must be submitted through www.ipp.gov For additional information, refer to the incorporated clause at 352.232-71 Electronic Submission of Payment Requests (APR

2026)(DEVIATION).

(Use Reverse and/or Attach Additional Sheets as Necessary)

HEREIN, IS ACCEPTED AS TO ITEMS:

XX

DATED

JERLYN R. BEGAY

. YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ARE

ARE

31c. DATE SIGNED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

27a. SOLICITATION INCORPORATES BY REFERENCE (FEDERAL ACQUISITION REGULATION) FAR 52.212-1, 52.212-4. FAR 52.212-3

AND 52.212-5 ARE ATTACHED. ADDENDA

26. TOTAL AWARD AMOUNT (For Government Use Only)

OFFER

STANDARD FORM 1449 (REV. 11/2021)

Prescribed by GSA - FAR (48 CFR) 53.212

ARE NOT ATTACHED.

ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30b. NAME AND TITLE OF SIGNER (Type or print)

30a. SIGNATURE OF OFFEROR/CONTRACTOR

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT: REFERENCE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 11/2021) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

If the Government's and Contractor's terms and conditions are in conflict, the Government's terms and conditions will prevail.

Period of Performance: 06/03/2026 to 09/03/2026

1 Contractor shall provide furniture and installation in accordance with Statement of Work

- Attachment A

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

46 2 of

Rev. 04/29/2026

SECTION B – CONTINUATION OF SF-1449

THIS PAGE IS INTENTIONALLY LEFT BLANK

SECTION C – CONTRACT CLAUSES

52.212-4 CONTRACT TERMS AND CONDITIONS –

COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

The following Federal Acquisition Regulation clauses also apply:

52.203-3 GRATUITIES APR 1984

52.203-6 RESTRICTIONS ON SUBCONTRACTOR SALES TO THE GOVERNMENT Alt I

NOV 2021

52.203-12 LIMITATION OF PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS

JUN 2020

52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS AND CONDUCT NOV 2021

52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST JUN 2020

52.203-17 CONTRACTOR EMPLOYEE WHISTLEBLOWER RIGHTS NOV 2023

52.203-19 PROHIBITION ON REQUIRING CERTAIN INTERNAL CONFIDENTIALITY

AGREEMENTS OR STATEMENTS

JAN 2017

52.204-9 PERSONAL IDENTITY VERIFICATION OF CONTRACTOR PERSONNEL JAN 2011

52.204-13 SYSTEM FOR AWARD MANAGEMENT MAINTENANCE NOV 2025

(DEVIATION)

52.204-14 SERVICE CONTRACT REPORTING REQUIREMENTS NOV 2025

(DEVIATION)

52.204-15 SERVICE CONTRACT REPORTING REQUIREMENTS FOR INDEFINITE-

DELIVERY CONTRACTS

NOV 2025

(DEVIATION)

52.204-91 CONTRACTOR IDENTIFICATION NOV 2025

(DEVIATION)

52.209-6 PROTECTING THE GOVERNMENT’S INTEREST WHEN

SUBCONTRACTING WITH CONTRACTORS DEBARRED, SUSPENDED, OR

PROPOSED FOR DEBARMENT

NOV 2025

(DEVIATION)

52.209-9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING

RESPONSIBILITY MATTERS

NOV 2025

(DEVIATION)

52.209-10 PROHIBITION ON CONTRACTING WITH INVERTED DOMESTIC

CORPORATIONS

NOV 2025

(DEVIATION)

52.213-1 RESERVED

52.219-3 NOTICE OF HUBZONE SET-ASIDE OR SOLE-SOURCE AWARD NOV 2025

(DEVIATION)

52.219-6 NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE NOV 2025

52.219-6 Alt I

NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I NOV 2025

(DEVIATION)

52.219-7 NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE NOV 2020

52.219-7 Alt I

NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I MAR 2020

52.219-8 UTILIZATION OF SMALL BUSINESS CONCERNS NOV 2025

(DEVIATION)

52.219-9 SMALL BUSINESS SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

52.219-9 Alt I

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE I NOV 2025

(DEVIATION)

52.219-9 Alt II

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE II NOV 2025

(DEVIATION)

52.219-9 Alt III

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE III NOV 2025

(DEVIATION)

52.219-9 Alt IV

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE IV NOV 2025

(DEVIATION)

52.219-13 NOTICE OF SET-ASIDE OF ORDERS MAR 2020

52.219-13 Alt I

RESERVED

52.219-16 LIQUIDATED DAMAGES—SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

52.219-27 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, SERVICE-

DISABLED VETERAN-OWNED SMALL BUSINESS (SDVOSB) CONCERNS

ELIGIBLE UNDER THE SDVOSB PROGRAM

NOV 2025

(DEVIATION)

52.219-28 POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION NOV 2025

(DEVIATION)

52.219-28 Alt I

POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION, WITH

ALTERNATE I

NOV 2025

(DEVIATION)

52.219-29 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO,

ECONOMICALLY DISADVANTAGED WOMEN-OWNED SMALL BUSINESS

CONCERNS

NOV 2025

(DEVIATION)

52.219-30 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, WOMEN-

OWNED SMALL BUSINESS CONCERNS ELIGIBLE UNDER THE WOMEN-

OWNED SMALL BUSINESS PROGRAM

NOV 2025

(DEVIATION)

52.219-33 NONMANUFACTURER RULE NOV 2025

(DEVIATION)

52.222-3 CONVICT LABOR NOV 2025

(DEVIATION)

52.222-19 CHILD LABOR—COOPERATION WITH AUTHORITIES AND REMEDIES NOV 2025

(DEVIATION)

52.222-35 EQUAL OPPORTUNITY FOR VETERANS NOV 2025

(DEVIATION)

52.222-36 EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES NOV 2025

(DEVIATION)

52.222-36

ALT I

EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES, WITH

ALTERNATE I

JUL 2014

52.222-37 EMPLOYMENT REPORTS ON VETERANS NOV 2025

(DEVIATION)

52.222-40 NOTIFICATION OF EMPLOYEE RIGHTS UNDER THE NATIONAL LABOR

RELATIONS ACT

NOV 2025

(DEVIATION)

52.222-41 SERVICE CONTRACT LABOR STANDARDS NOV 2025

(DEVIATION)

52.222-43 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT (MULTIPLE YEAR AND OPTION

CONTRACTS)

NOV 2025

(DEVIATION)

52.222-44 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT

NOV 2025

(DEVIATION)

52.222-50 COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

52.222-50 Alt I

COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

52.222-51 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR MAINTENANCE, CALIBRATION, OR

REPAIR OF CERTAIN EQUIPMENT—REQUIREMENTS

NOV 2025

(DEVIATION)

52.222-53 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR CERTAIN SERVICES—

REQUIREMENTS

NOV 2025

(DEVIATION)

52.222-54 EMPLOYMENT ELIGIBILITY VERIFICATION NOV 2025

(DEVIATION)

52.222-55 MINIMUM WAGES FOR CONTRACTOR WORKERS UNDER EXECUTIVE

ORDER 14026

NOV 2025

(DEVIATION)

52.222-62 PAID SICK LEAVE UNDER EXECUTIVE ORDER 13706 NOV 2025

(DEVIATION)

52.222-90 ADDRESSING DEI DISCIMINATION BY FEDERAL CONTRACTORS APR 2026

(DEVIATION)

52.223-2 REPORTING OF BIOBASED PRODUCTS UNDER SERVICE AND

CONSTRUCTION CONTRACTS

NOV 2025

(DEVIATION)

52.223-5 POLLUTION PREVENTION AND RIGHT-TO-KNOW INFORMATION MAY 2024

52.223-11 OZONE-DEPLETING SUBSTANCES NOV 2025

(DEVIATION)

52.223-12 MAINTENANCE, SERVICE, REPAIR, OR DISPOSAL OF REFRIGERATION

EQUIPMENT AND AIR CONDITIONERS

NOV 2025

(DEVIATION)

52.223-23 SUSTAINABLE PRODUCTS NOV 2025

(DEVIATION)

52.224-1 PRIVACY ACT NOTIFICATION APR 1984

52.224-2 PRIVACY ACT APR 1984

52.224-3 PRIVACY TRAINING JAN 2017

52.224-3

ALT I

PRIVACY TRAINING, WITH ALTERNATE I JAN 2017

52.225-1 BUY AMERICAN-SUPPLIES NOV 2025

52.225-1 Alt I

BUY AMERICAN-SUPPLIES, WITH ALTERNATE I OCT 2022

52.225-3 BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT NOV 2025

(DEVIATION)

52.225-3

ALT I

RESERVED

52.225-3 Alt II

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE II

NOV 2025

(DEVIATION)

52.225-3 Alt III

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE III

NOV 2025

(DEVIATION)

52.225-3 Alt IV

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE IV

NOV 2025

(DEVIATION)

52.225-5 TRADE AGREEMENTS NOV 2023

52.225-14 INCONSISTENCY BETWEEN ENGLISH VERSION AND TRANSLATION OF

CONTRACT

FEB 2000

52.225-19 CONTRACTOR PERSONNEL IN A DESIGNATED OPERATIONAL AREA OR

SUPPORTING A DIPLOMATIC OR CONSULAR MISSION OUTSIDE THE

UNITED STATES

MAY 2020

52.225-26 CONTRACTORS PERFORMING PRIVATE SECURITY FUNCTIONS

OUTSIDE THE UNITED STATES

OCT 2016

52.226-1 UTILIZATION OF INDIAN ORGANIZATIONS AND INDIAN-OWNED

ECONOMIC ENTERPRISES

NOV 2025

(DEVIATION)

52.226-5 RESTRICTIONS ON SUBCONTRACTING OUTSIDE DISASTER OR

EMERGENCY AREA

NOV 2025

(DEVIATION)

52.226-6 PROMOTING EXCESS FOOD DONATION TO NONPROFIT

ORGANIZATIONS

NOV 2025

(DEVIATION)

52.226-8 ENCOURAGING CONTRACTOR POLICIES TO BAN TEXT MESSAGING

WHILE DRIVING

MAY 2024

52.229-12 TAX ON CERTAIN FOREIGN PROCUREMENTS AUG 2025

(DEVIATION)

52.232-18 AVAILABILITY OF FUNDS APR 1984

52.232-29 TERMS FOR FINANCING OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

52.232-30 INSTALLMENT PAYMENTS OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

52.232-33 PAYMENT BY ELECTRONIC FUNDS TRANSFER—SYSTEM FOR AWARD

MANAGEMENT

OCT 2018

52.232-34 PAYMENT BY ELECTRONIC FUNDS TRANSFER—OTHER THAN SYSTEM

FOR AWARD MANAGEMENT

JUL 2013

52.232-36 PAYMENT BY THIRD PARTY NOV 2025

(DEVIATION)

52.232-40 PROVIDING ACCELERATED PAYMENTS TO SMALL BUSINESS

SUBCONTRACTORS

MAR 2023

52.232-90 FAST PAYMENT PROCEDURE NOV 2025

(DEVIATION)

52.233-3 PROTEST AFTER AWARD NOV 2025

52.233-4 APPLICABLE LAW FOR BREACH OF CONTRACT CLAIM NOV 2025

(DEVIATION)

52.237-2 PROTECTION OF GOVERNMENT BUILDING, EQUIPMENT, AND

VEGETATION

APR 1984

52.237-3 CONTINUITY OF SERVICES JAN 1991

52.240-91 SECURITY PROHIBITIONS AND EXCLUSIONS NOV 2025

(DEVIATION)

52.240-91 Alt I

SECURITY PROHIBITIONS AND EXCLUSIONS, WITH ALTERNATE I NOV 2025

(DEVIATION)

52.240-92 SECURITY REQUIREMENTS NOV 2025

(DEVIATION)

52.240-92 Alt II

SECURITY REQUIREMENTS WITH ALTERNATE II NOV 2025

(DEVIATION)

52.240-93 BASIC SAFEGUARDING OF COVERED CONTRACTOR INFORMATION

SYSTEMS

NOV 2025

(DEVIATION)

52.242-5 PAYMENTS TO SMAL BUSINESS SUBCONTRACTORS JAN 2017

52.242-13 BANKRUPTCY JUL 1995

52.244-2 SUBCONTRACTS JUN 2020

52.244-6 SUBCONTRACTS FOR COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

52.245-1 GOVERNMENT PROPERTY SEP 2021

52.245-2 GOVERNMENT PROPERTY INSTALLATION OPERATION SERVICES APR 2012

52.245-9 USE AND CHARGES APR 2012

52.247-64 PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS

NOV 2025

(DEVIATION)

52.247-64 Alt I

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE I

APR 2003

52.247-64 Alt II

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE II

NOV 2021

52.219-14 LIMITATIONS ON SUBCONTRACTING NOV 2025

(a) This clause does not apply to the unrestricted portion of a partial set-aside.

(b) Definition. Similarly situated entity, as used in this clause, means a first-tier subcontractor, including an independent contractor, that—

(1) Has the same small business program status as that which qualified the prime contractor for the award (e.g., for a small business set-aside contract, any small business concern, without regard to its socioeconomic status); and

(2) Is considered small for the size standard under the North American Industry Classification System (NAICS) code the prime contractor assigned to the subcontract.

(c) Applicability. This clause applies only to—

(1) Contracts that have been set aside for any of the small business concerns identified in 19.000(a)(3);

(2) Part or parts of a multiple-award contract that have been set aside for any of the small business concerns identified in 19.000(a)(3);

(3) Contracts that have been awarded on a sole-source basis in accordance with subparts 19.105, 19.106, 19.107, and 19.108;

(4) Orders expected to exceed the simplified acquisition threshold and that are set aside for small business concerns under multiple-award contracts, as described in 8.4 and 16.5;

(5) Orders, regardless of dollar value, that are set aside in accordance with section 19.105, 19.106, 19.107, and 19.108 under multiple-award contracts, as described in 8.4 and 16.5; and

(6) Contracts using the HUBZone price evaluation preference to award to a HUBZone small business concern unless the concern waived the evaluation preference.

(d) Independent contractors. An independent contractor shall be considered a subcontractor.

(e) By submission of an offer and execution of a contract, the Contractor agrees that in performance of a contract assigned a North American Industry Classification System (NAICS) code for—

(1) Services (except construction), it will not pay more than 50 percent of the amount paid by the Government for contract performance to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 50 percent subcontract amount that cannot be exceeded. When a contract includes both services and supplies, the 50 percent limitation shall apply only to the service portion of the contract;

(2) Supplies (other than procurement from a nonmanufacturer of such supplies), it will not pay more than 50 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 50 percent subcontract amount that cannot be exceeded. When a contract includes both supplies and services, the 50 percent limitation shall apply only to the supply portion of the contract;

(3) General construction, it will not pay more than 85 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 85 percent subcontract amount that cannot be exceeded; or

(4) Construction by special trade contractors, it will not pay more than 75 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 75 percent subcontract amount that cannot be exceeded.

(f) The Contractor shall comply with the limitations on subcontracting as follows:

(1) For contracts, in accordance with paragraphs (c)(1), (2), (3) and (6) of this clause—

By the end of the base term of the contract and then by the end of each subsequent option period; or

By the end of the performance period for each order issued under the contract.

(2) For orders, in accordance with paragraphs (c)(4) and (5) of this clause, by the end of the performance period for the order.

(g) A joint venture agrees that, in the performance of the contract, the applicable percentage specified in paragraph (e) of this clause will be performed by the aggregate of the joint venture participants.

(1) In a joint venture comprised of a small business protégé and its mentor approved by the Small Business Administration, the small business protégé shall perform at least 40 percent of the work performed by the joint venture. Work performed by the small business protégé in the joint venture must be more than administrative functions.

(2) In an 8(a) joint venture, the 8(a) participant(s) shall perform at least 40 percent of the work performed by the joint venture. Work performed by the 8(a) participants in the joint venture must be more than administrative functions.

(End of Clause)

52.252-2 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):

Revolutionary FAR Overhaul - FAR Overhaul - FAR Part Deviation Guidance | Acquisition.GOV

Federal Acquisition Regulation - https://www.acquisition.gov/browse/index/far

Department of Health and Human Services Acquisition Regulation – https://www.acquisition.gov/hhsar

(End of clause)

52.252-6 AUTHORIZED DEVIATIONS IN CLAUSES NOV 2020

(a)The use in this solicitation or contract of any Federal Acquisition Regulation (48 CFR Chapter 1) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the date of the clause.

(b)The use in this solicitation or contract of any Department of Health and Human Services (48 CFR Chapter 3) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the name of the regulation.

The following Department of Health and Human Services Acquisition Regulation clauses also apply:

352.203-70 ANTI-LOBBYING DEC 2015

352.208-70 PRINTING AND DUPLICATION DEC 2015

352.211-3 PAPERWORK REDUCTION ACT DEC 2015

352.219-71 MENTOR-PROTÉGÉ PROGRAM REPORTING REQUIREMENTS JAN 2010

352.223-70 SAFETY AND HEALTH DEC 2015

352.224-70 PRIVACY ACT DEC 2015

352.226-6 INDIAN ECONOMIC ENTERPRISE SUBCONTRACTING

LIMITATIONS

MAR 2022

352.227-70 PUBLICATIONS AND PUBLICITY DEC 2015

352.231-70 SALARY RATE LIMITATION DEC 2015

352.237-70 PRO-CHILDREN ACT DEC 2015

352.237-71 CRIME CONTROL ACT – REPORTING OF CHILD ABUSE DEC 2015

352.237-72 CRIME CONTROL ACT – REQUIREMENTS FOR BACKGROUND

CHECKS

DEC 2015

352.237-73 INDIAN CHILD PROTECTION AND FAMILY VIOLENCE ACT DEC 2015

352.232-71 ELECTRONIC SUBMISSION OF PAYMENT

REQUESTS

APR 2026

(a) Definitions. As used in this clause –

Payment request means a bill, voucher, invoice, or request for contract financing payment with associated supporting documentation. The payment request must comply with the requirements in FAR 32.905(b) and the applicable payment clause included in this contract.

(b) Submission instructions. Except as provided in paragraph (c) of this clause, the Contractor must submit payment requests electronically using the Department of Treasury Invoice Processing Platform (IPP) or successor system. Information regarding IPP, including IPP Customer Support contact information, is available at www.ipp.gov or any successor site.

(c) Alternate submission procedures. The Contractor may submit payment requests using other than IPP only when the Contracting Officer authorizes alternate procedures in writing.

(d) Submission of alternate payment procedures authorization. If alternate payment procedures are authorized, the Contractor shall include a copy of the Contracting Officer’s written authorization with each payment request.

The following local Indian Health Service, Navajo Area terms also apply:

NAIHS-ACQ-09 UNAUTHORIZED COMMITMENTS NOV 2025

(a) Definitions.

Contracting Officer means a person with the authority to enter into, administer, and/or terminate contracts and make related determination and findings.

Ratification means the act of approving an unauthorized commitment by an official who has the authority to do so.

Unauthorized Commitment (UAC) means an agreement that is not binding solely because the Government representative who made it lacked the authority to enter into that agreement on behalf of the Government.

(b) Policy.

The Government is not bound by agreements with, or contractual commitments made to, prospective contractors by individuals who do not have delegated contracting authority. Unauthorized commitments do not follow the appropriate process for the expenditure of Government funds. Consequently, the Government may not be able to ratify certain actions, putting a contractor at risk for taking direction from a Federal official other than the contracting officer (see FAR 1.403-2). Government employees responsible for unauthorized commitments are subject to disciplinary action. Contractors perform at their own risk when accepting direction from unauthorized officials. Failure to follow statutory and regulatory processes for the expenditure of Government funds is a very serious matter.

(c) Procedure.

Any agreement, modification, or change to a contractual agreement made by a government personnel who lack authority will be deemed an unauthorized commitment. The Government is not liable to the Contractor or under the terms of the contract, financially or otherwise – unless the unauthorized commitment successfully passes the ratification process.

The ratification process does not have any lead time, nor does the Government make any promise that an unauthorized commitment will be ratified and, therefore, the Contractor would be paid. The Contractor proceeds at its own risk if any of the terms of the contract are altered, changed, or modified without the written concurrence by a Contracting Officer.

NAIHS-ACQ-11 CONTRACTOR PERSONNEL SECURITY AND

ACCESS

MAY 2025

(a) Definitions. As used in this clause—

Agency access means access to NAIHS facilities, sensitive information, information systems or other NAIHS resources.

Applicant means a contractor employee for whom the Contractor applies for a NAIHS identification card.

Contractor employee means a prime contractor and subcontractor employee who requires agency access to perform work under a NAIHS contract.

Identification card (or “ID card”) means a government issued or accepted identification card such as a Personal Identity Verification (PIV) card.

Issuing office means the NAIHS entity that issues identification cards to contractor employees.

Local security servicing organization means the NAIHS entity that provides security services to the NAIHS organization sponsoring the contract.

(b) Risk and sensitivity level designations. For contracts requiring access to NAIHS facilities, sensitive information, information systems or other NAIHS resources, contractor employees will be required to complete background investigations, identity proofing, and government identification card application procedures to determine suitability for access. NAIHS will assign a risk and sensitivity level designation to the overall contract and/or to contractor employee positions by category, group or individual. The risk and sensitivity level designations will be the basis for determining the level of personnel security processing required for contractor employees. The following risk and sensitivity level designations and associated level of processing are required, and each level includes the prior levels—

(1) Tier 1 Non-Sensitive, Low risk level: National Agency Check with Written Inquiries (NACI);

(2) Tier 2 Non-Sensitive (Public Trust), Moderate risk level: Minimum Background Investigation (MBI);

and

(3) Tier 4 Non-Sensitive (Public Trust), High risk level: Background Investigation.

(c) Pre-screening of contractor employees. The Contractor must pre-screen individuals designated for employment under any NAIHS contract by verifying minimal suitability requirements to ensure that only candidates that appear to meet such requirements are considered for contract employment, and to mitigate the burden on the Government of conducting background investigations on objectionable applicants. The Contractor must exercise due diligence in pre-screening all employees prior to submission to NAIHS for agency access. NAIHS may decline to grant agency access to a contractor employee for reasons including, but not limited to the following activities under 5 CFR 731, P.L. 101-630, and P.L. 101-647—

(1) Conviction of a felony, a crime of violence, or a misdemeanor involving moral turpitude;

(2) Falsification of information entered on forms or of other documents submitted;

(3) Improper conduct including criminal, infamous, dishonest, immoral, or notoriously disgraceful conduct or other conduct adverse to the Government regardless of whether the conduct is directly related to the contract; and

(4) Any behavior judged to pose a potential threat to NAIHS facilities, sensitive information, information systems or other resources.

(d) Citizenship status. The Contractor must monitor a non-citizen's continued authorization for employment in the United States. The Contractor must provide documentation to the Contracting Officer or the Contracting Officer's Representative (COR) during the background investigation process that validates that the E-Verify requirement has been met for each contractor employee. If applicable, refer to the incorporated clause at 52.222-54 Employment Eligibility Verification.

(e) Background investigation and adjudication. A contractor employee must have a suitable pre-employment adjudication of background investigation before NAIHS will issue an ID card to the contractor employee granting access to NAIHS facilities, sensitive information, information systems or other NAIHS resources. NAIHS may accept favorable adjudications of background investigations from other Federal agencies when applicants have held PIV cards issued by those agencies with no break in service. A favorable adjudication does not preclude NAIHS from initiating a new investigation when deemed necessary. At a minimum, the FBI National Criminal History Check (fingerprint check) must be favorably completed before a NAIHS identification card can be issued. Each Contractor must use the Office of Personnel Management's (OPM) e-APP system to complete any required investigative forms. Instructions for obtaining fingerprints will be provided by the COR or Contracting Officer. The NAIHS Personnel Security Office is responsible for adjudicating the suitability of contractor employees.

(f) Agency access denied. Upon contract award, NAIHS will initiate the agency access procedure for all contractor employees requiring access to NAIHS facilities, sensitive information, information systems and other NAIHS resources for contract performance. NAIHS may deny agency access to any individual about whom an adverse suitability determination is made. Failure to submit the required security information or to truthfully answer all questions shall constitute grounds for denial of access. The Contractor must not direct its employees to work under the contract until the COR or Contracting Officer provides notice of approval. Where a proposed contractor employee is denied agency access by the Government or, if for any reason a proposed application is withdrawn by the Contractor during the agency access process, the additional costs and administrative burden for conducting additional background investigations caused by a lack of effective prescreening or planning on the part of the Contractor may be considered as part of the Contractor's overall performance evaluation.

(g) Identification card application process. The Contracting Officer (CO) or COR will be the NAIHS ID card Sponsor and point of contact for the Contractor's application for a NAIHS ID card. The CO/COR shall review the NAIHS ID card request before sending the requested applicant’s information to Personnel Security Office. An applicant may be issued either a Personal Identity Verification (PIV) card that meets the standards of Homeland Presidential Security Directive (HSPD–12). The following applies—

(1) PIV card. The applicant must complete the e-App on-line application for a PIV card;

(2) The applicant must provide two forms of identity source documents in original form to NAIHS. The identity source documents must come from the list of acceptable documents included in Form F–9, OMB No. 1115–0136, Employment Eligibility Verification. At least one document must be a valid State or Federal government-issued picture identification. For a PIV card, the applicant may be required to appear in-person a second time for enrollment and activation.

(h) Identification card custody and control. The Contractor is responsible for the custody and control of all forms of government identification issued by NAIHS to contractor employees for access to NAIHS facilities, sensitive information, information systems and other NAIHS resources. The Contractor shall:

(1) Provide a listing of personnel for whom an identification (ID) card is requested to the COR or PM who will provide a copy of the listing to the card issuing office. This may include Contractor and subcontractor personnel. Follow issuing office directions for submittal of an application package(s).

(2) While visiting or performing work on a NAIHS facility, as specified by the issuing office, PM or COR, ensure that contractor employees prominently display their ID card.

(3) Immediately notify the COR or, if the COR is unavailable, the Contracting Officer when a contractor employee's status changes and no longer requires agency access (e.g., employee's transfer, completion of a project, retirement, removal from work on the contract, or termination of employment) that may affect the employee's eligibility for access to the facility, sensitive information, or resources.

(4) Promptly deliver to the issuing office: (a) all ID cards assigned to an employee who no longer requires access to the facility; and (b) all expired ID cards within five (5) days of their expiration or all cards at time of contract termination, whichever occurs first.

(5) Immediately report any lost or stolen ID cards to the issuing office and follow its instructions.

(i) The Contractor is responsible for maintaining and safeguarding the NAIHS ID card upon issuance to the contractor employee. The Contractor must ensure that contractor employees comply with NAIHS requirements concerning the renewal, loss, theft, or damage of an ID card. The Contractor must immediately notify the COR or, if the COR is unavailable, the Contracting Officer when an ID card is lost, stolen or damaged.

(ii) Failure to comply with the requirements for custody and control of NAIHS ID cards may result in withholding final payment or contract termination based on the potential for serious harm caused by inappropriate access to NAIHS facilities, sensitive information, information systems or other NAIHS resources.

(iii) Specific actions and activities are required in certain events—

(A) Renewal. A contractor employee's NAIHS issued ID card is valid for a maximum of five years or until the contract expiration date (including option periods), whichever occurs first. The renewal process should begin six weeks before the PIV card expiration date. If a PIV card is not renewed before it expires, the contractor employee will be required to sign-in daily for facility access and may have limited access to information systems and other resources.

(B) Lost/stolen. Immediately upon detection, the Contractor or contractor employee must report a lost or stolen NAIHS ID card to the COR, or if the COR is unavailable, the Contracting Officer, the issuing office, or the local servicing security organization. The Contractor must submit an incident report within 48 hours, through the COR or, if the COR is unavailable, the Contracting Officer, the issuing office, or the local security servicing organization describing the circumstances of the loss or theft. The Contractor must also report a lost or stolen PIV card through the NAIHS on-line registration system. If the loss or theft is reported by the Contractor to the local police, a copy of the police report must be provided to the COR or Contracting Officer.

From the date of notification to NAIHS, the Contractor must wait three days before getting a replacement ID card. During the 3-day wait period, the contractor employee must sign in daily for facility access.

(C) Replacement. An ID card will be replaced if it is damaged, contains incorrect data, or is lost or stolen for more than 3 days, provided there is a continuing need for agency access to perform work under the contract.

(D) Surrender of ID cards. Upon notification that routine access to NAIHS facilities, sensitive information, information systems or other NAIHS resources is no longer required, the Contractor must surrender the NAIHS issued ID card to the COR, or if the COR is unavailable, the Contracting Officer, the issuing office, or the local security servicing organization in accordance with agency procedures.

(i) Flow down of clause. The Contractor is required to include this clause in any subcontracts at any tier that require the subcontractor or subcontractor's employees to have access to NAIHS facilities, sensitive information, information systems or other resources.

NAIHS-ACQ-19 REAL ID ACT MAY 2025

In alignment with the Department of Homeland Security (DHS) and the Transportation Security Administration (TSA), the U.S. Department of Health and Human Services (HHS) will fully implement and enforce REAL ID Act requirements for all HHS facility access beginning May 7, 2025. All individuals entering HHS-owned, leased, or operated facilities must present a REAL ID-compliant credential or another federally approved form of identification. Below is the list of acceptable forms of ID.

• State-issued Enhanced Driver’s License

• U.S. passport

• U.S. passport card

• DHS trusted traveler cards (Global Entry, NEXUS, SENTRI, FAST)

• U.S. Department of Defense ID, including IDs issued to dependents

• Permanent resident card

• Border crossing card

• An acceptable photo ID issued by a federally recognized Tribal Nation/Indian Tribe, including Enhanced

Tribal Cards (ETCs)

• HSPD-12 PIV card

• Foreign government-issued passport

• Canadian provincial driver's license or Indian and Northern Affairs Canada card

• Transportation worker identification credential

• U.S. Citizenship and Immigration Services Employment Authorization Card (I-766)

• U.S. Merchant Mariner Credential

• Veteran Health Identification Card (VHIC)

NAIHS-ACQ-20 PROTECTING FEDERAL EMPLOYEES AND

THE PUBLIC FROM EXPOSURE TO TOBACCO

SMOKE IN THE FEDERAL WORKPLACE

APR 2026

In accordance with Executive Order 13058 “Protecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace,” and the Assistant Secretary for Health memorandum “Prohibition of Tobacco Use in HHS Occupied Facilities,” the use of tobacco products, in any form, is strictly prohibited at IHS-operated properties including, but not limited to:

1. All interior and exterior spaces of IHS-operated properties.

2. All HIS-operated spaces in multi-tenant buildings.

3. All Government vehicles regardless of their location.

4. Private vehicles while on IHS property.

The IHS continues to recognize the value and efficacy of patients’ traditional beliefs and ceremonial practices. The use of tobacco products for ceremonial purposes is allowed in the designated traditional healing room, including any space designated for a ceremony, or in a patient’s hospital room.

To the maximum extent practicable, Contractor must notify the Contracting Officer’s Representative in advance of using tobacco products in a ceremony.

SECTION D – DOCUMENTS, EXHIBITS, ATTACHMENTS, ETC.

Attachment A – Statement of Work

Attachment B – Office Measurements

Attachment C – Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form

Attachment D – Pre-Construction Risk Assessment

Tohatchi Health Center

Scope of Work

Business Office Furniture

Scope of Work

The contractor shall provide all necessary labor, equipment and supplies to install workstations/furniture to rooms 156, 157 and 158.

Deliverables

1. New office furniture. All furniture to be wipeable and with micro-bacterial surfaces.

a. Two U Shaped Desks with Hutch.

i. Electric adjustable height desk.

ii. Combo file with 2 box drawers, 1 file drawer and 1 lateral file drawer.

111. Hutch with 2 silver framed glass doors.

b. One Sit-to-Stand Full Casing Desk

i. Electric adjustable height desk.

c. One 4 Shelf Bookcase with Doors Covering Lower¾ of Unit.

d. One 29 1/2 inch Height Laminate Wood Door Storage Cabinet

e. One 2 Drawer Under Desk Mobile File Pedestal

f. Two 2 Drawer Lateral File with Hutch

g. One 42 inch Wide x 24 inch Depth Reversible Return

h. One PL142 Half Leg

i. One Under Desk Full Box/File Pedestal

j. Two Big & Tall Dual Layer Air Grid Mesh Manager Chairs

k. One High Back Multifunction Mesh Executive Office Chair

l. All hardware to connect furniture to complete installation.

m. Site visit to verify measurements, door locations, power and data outlets.

General Conditions

1. Codes and Standard. The Contractor shall adhere to all the following code and standards requirements for work performed.

a. 2018 Edition NFPA 99

b. Occupational Safety and Health Act (OSHA)- CFRA1926

2. Project Safety

Attachment A

a. Contractor shall provide all worksite safety equipment.

b. Housekeeping accomplished on a daily basis. Contractor will remove all debris and trash generated by this project to be disposed of properly at a state certified disposal site in accordance with national, state and local environmental regulations.

c. Contractor shall be responsible for complete and strict compliance with Gallup Service Unit Facility policies, including safety policy.

d. Pre-Construction Control Risk Assessment (PCRA) shall be approved and signed before any work starts.

e. Contractor(s) shall sign in and out with Security room 101.

3. Product Specifications

a. Office desks

4. Submittals

a. Submittals of all products and materials. Provide in scanned PDF format.

5. Inspection

a. The Government has the right to inspect all aspects of work performed.

b. Final acceptance will be based on an acceptable final inspection.

6. Quality Assurance

a. Only materials approved on product submittal are used. No substitution without prior approval by Contracting Officer.

b. All new materials shall be installed per manufacturer's instructions.

c. All work to be performed by a contractor specialized in the specific trade required on this project.

7. Execution

a. All activities shall be coordinated with Tohatchi Health Center Facility Management staff to ensure there are no detrimental impact on the day-to-day operations of the clinic. Advance notification of 72 hours is required to properly coordinate issues and delays.

b. Contractor is responsible for obtaining all appropriate signed forms and permits prior to starting any work.

c. Contractor shall verify all existing site conditions and measurements prior to removal and installation.

d. Facility staff will terminate electrical power to workstations and IT staff will provide data lines and jacks for the work stations.

8. Inspection

a. The government reserves the right to inspect all aspects of work performed, including hiring a third party inspector to verify proper installation and operation.

b. Contractor is required to demonstrate full and complete operation of all work performed.

c. Final acceptance will be based on an acceptable final inspection, including final verification testing of all materials and workmanship.

9. Project Schedule

a. The contractor shall provide a detailed schedule indicating starting and completion dates of the project.

b. Contractor shall work with local contact for job access and work time coordination.

c. Contractor shall provide a coordinated schedule to Contract Officer

Representative (COR) and Contract Specialist (CS).

d. Hours of operation for the facility are 8:00 am - 4:30 pm, Monday-Friday

(excluding federal holidays). Work outside these hours must be submitted three business days in advance in writing to the Contract Officer for approval.

1O. Performance Period

a. From date of award through three months to complete install of all furniture.

11. Final Payment

a. Final payment will not be authorized until all work is complete, including punch list items and final inspection has been made.

b. Close out documents shall include approved submittals and copies of warranty letters.

12. Warranty

a. Contractor shall warranty all work for one year from date of acceptance.

9’6

11’6” 108 Sq Ft

10’4” 98 Sq Ft

10’2” 97 Sq Ft Window

Attachment B

DEPARTMENT OF HEALTH & HUMAN SERVICES

Indian Health Service

Office of Management Services Division of Acquisition Policy (DAP)

5600 Fishers Lane Rockville, MD 20857

INDIAN HEALTH SERVICE

BUY INDIAN ACT

INDIAN ECONOMIC ENTERPRISE

REPRESENTATION FORM

SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________

PROJECT TITLE: ________________________________________________________

DATE: ___________________________________________________________________

In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.

The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:

(1) At the time an offer is made in response to this solicitation;

(2) At the time of contract award; and

(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.

Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).

Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.

False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.

REPRESENTATION

The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.

Name of the 51% owner of IEE Firm

Certifying Signature

Print Name

Name of Federally Recognized Tribal Entity

Business Name

UEI Number

Attachment C

08/14/18 Update

Pre-Construction Risk Assessment – Cover Page Project Title: Project/Contract #:

GIMC Coordinator: PCRA Submit Date:

Project Conducted by:

Fac. Mgmt. I.T. Telecom Clin. Eng.

Contractor: __________________________

Proposed Start Date:

Staff/Cont. Name: Est. Duration:

Supervisor Name: Est. Complete Date:

Telephone: Date Project Completed: Email:

Project Description: (include specific sites and tasks)

ICRA Classification Class I Class II Class III* Class IV*

Section 1. Initial Project Impact Review

Topic Will project negatively impact or involve…? No Yes Responses (If YES to any)

Fire Safety Section 2A(1)

Ceiling tile removal (less than 4 hours total) Complete Above the Ceiling Access Permit (ACAP) Existing fire-stop; minor barrier penetrations

Fire Safety Section 2A(2)

Fire detection/alarm/suppression systems Complete Interim Life Safety Measure (ILSM) evaluation. Exit paths or fire/smoke barriers

Hot work practices

Extra fire load or flammable materials

Utilities Section 2B

Water, sewer, electricity, steam, or HVAC (including outside air intakes)

Complete the Utility System Risk Assessment (USRA)

Medical gases or vacuum

Call systems, telephones, or IT systems

Environmental/ Occupational Section 2C

Lead or asbestos containing materials Complete Env./Occ. Risk Assessment (EORA) Chemical hazards (i.e. mercury, volatile organics)

Exposure to infectious agents or mold

Security Section 2D

Security systems (badge readers, cameras) Complete Security Risk Assessment (SRA) Security processes (tours, foot/vehicle traffic)

Infection Control Section 2E

Patient care areas or critical utilities Complete an Infection Control Risk Assessment (ICRA) Moderate to high levels of dust, noise, vibration

More than one work shift

Project Approval Evaluator Signature & Title Date: Required for: All

Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: USRA and ICRA

Supervisor (affected area) Date: Required for: All

Project Close-out Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: ICRA-Class III & IV

Supervisor (affected area) Date: Required for: All

Attachment D

Section 2A(1). Above Ceiling Permit

Project Title: Project/Contract #:

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Topic Issue for Evaluation No Yes Responses (If NO to any) Date Completed

GSU Training 1. Have all supervisors/workers been trained on fire safety requirements

Schedule training with Facility Mgr or Safety Ofcr

Review policy and sign acknowledgement below.

2. Has supervisor read above ceiling access policy?

Project Plans/ Drawings

1. Has a cable routing plan been provided to Facility Manager?

Provide Facility Mgr with written plan or drawing.

If req’d by Facility Mgr, request and redline Life Safety Plan drawings

2. Is a redlined drawing/CAD over the Life Safety Plan needed?

(GIMC use only)

Project Details 1. Have descriptions/fire ratings for any materials to be installed been provided?

Provide complete project details to Facility Manager; or utilize facility approved systems/materials.

2. Have additions of cables/wires to pre-existing pathways/sleeves been reviewed and found to comply with allowable loads?

3. Have descriptions of UL compliant firestop systems been provided; or will facility approved systems be used?

4. Have descriptions of approved hanger/ support systems been provided; or will facility approved systems be used?

5. Have product details for all firestop systems/materials been provided?

Pre-work inspection

1. Has a pre-work inspection been conducted?

Conduct pre-work inspection and notify Facility Manager of existing deficiencies.

2. Have any existing unprotected penetrations been identified?

3. Have existing items supported by sprinkler piping been identified?

ILSM 1. Will any ceiling/tile grid, fire/smoke barrier, or firestop system be compromised for more than 4 hours or beyond the end of the work day, without a temporary code compliant protection system/ methodology?

Conduct a full ILSM evaluation

ACA Permit Approval Facility Manager Signature Date:

ACA Permit Close-out

ABOVE CEILING ACCESS PERMIT

PERMIT MUST BE PROMINENTLY DISPLAYED AT THE JOB SITE

NOTICE TO PERMIT HOLDER

READ CAREFULLY

Certain spaces (such as above ceiling tile grids or utility closets) are restricted to authorized personnel, and are controlled in GSU facilities.

Access to these spaces is a privilege, which may be denied for those who do not comply with the Above Ceiling Access Permit Policy. This applies to all staff, as well as vendors and contractor personnel.

This form and the preceding pages are the permit and must be displayed at all times while creating new, or accessing existing penetrations in smoke or fire barriers. It must also be displayed when working above ceiling tile grids, in utility closets or in any other space identified as CONTROLLED SPACE.

Persons found working in these spaces without a valid permit visible are in violation of the ABOVE CEILING ACCESS PERMIT POLICY, and may lose their access privileges. Chronic non-compliers will be disciplined.

SOME EXAMPLES OF POLICY VIOLATIONS:

Accessing a controlled space without a permit

Failure to hold and display a valid permit

Failure to close out a permit

Performing work outside the scope of a permit

Providing false information to a permit issuer

Falsifying data on a permit

Allowing someone to work under the scope of a permit issued in another’s name

All individuals performing work in a CONTROLLED SPACE shall read and be familiar with the ABOVE CEILING ACCESS PERMIT POLICY, copies of which can be obtained in Facility Management.

I have read and understand the ABOVE CEILING ACCESS PERMIT POLICY, and agree to comply with it.

Staff/Contractor Signature Date:

Section 2A(2).