SPM2D1-09-D-8321 attachment.pdf

ORDER FOR SUPPLIES OR SERVICES

1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO. 4. REQUISITION/PURCH REQUEST NO.3. DATE OF ORDER/CALL

(YYYYMMMDD)

5. PRIORITY

6. ISSUED BY 7. ADMINISTERED BY If other than 6 8. DELIVERY FOB

9. CONTRACTOR

NAME

AND

ADDRESS

10. DELIVER TO FOB POINT BY (Date)

(YYYYMMMDD)

12. DISCOUNT TERMS

13. MAIL INVOICES TO THE ADDRESS IN BLOCK

(See Schedule if other)

11. X IF BUSINESS IS

14. SHIP TO 15. PAYMENT WILL BE MADE BY MARK ALL

PACKAGES AND

PAPERS WITH

IDENTIFICATION

NUMBERS IN

BLOCKS 1 AND 2.

16.

TYPE

OF

ORDER ACCEPTANCE.

(YYYYMMMDD)

17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE

18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES

20. QUANTITY

ORDERED/ ACCEPTED* 21.UNIT 22. UNIT

PRICE

23. AMOUNT

* If quantity accepted by the Government is same as quantity ordered, indicate by X.

If different, enter actual quantity accepted below quantity ordered and encircle.

24. UNITED STATES OF AMERICA 25. TOTAL

26.

DIFFERENCES

27a. QUANTITY IN COLUMN 20 HAS BEEN

INSPECTED RECEIVED

ACCEPTED, AND CONFORMS TO

THE CONTRACT EXCEPT AS NOTED:

YYYYMMMDD

28. SHIP. NO. 29. D.O. VOUCHER NO. 30. INITIALS

32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR

g. E-MAIL ADDRESS

36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT.

YYYYMMMDD

b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

DD FORM 1155, DEC 2001

37. RECEIVED

AT

38. RECEIVED BY Print 39. DATE RECEIVED

YYYYMMMDD

31. PAYMENT

40. TOTAL CON-

TAINERS

41. S/R ACCOUNT NUMBER 42. S/R VOUCHER NO.

34. CHECK NUMBER

35. BILL OF LADING NO.

X

X

X

13PAGE 1 OF

2013 Dec 27

Patricia P McKay Digitally signed by Patricia P McKay DN: cn=Patricia P McKay, o=Philips Healthcare, ou=Director, Government Contracts, email=pat.mckay@philips.com, c=US Date: 2013.12.27 09:30:42 -08'00'

HARTZELL.JACLYN.M

.1284045013

Digitally signed by HARTZELL.JACLYN.M.1284045013 DN: c=US, o=U.S. Government, ou=DoD, ou=PKI, ou=DLA, cn=HARTZELL.JACLYN.M.1284045013 Date: 2013.12.27 12:47:06 -05'00'

CONTINUED ON NEXT PAGE

Form

Continuation Pages For Reference Only:

CLINS 0001-0006

Requisition: FX7059-3227-G001 Sales Order: 372877908 Purchase Request: 51354832

MIPR#: F1ATB23227G001

Delivery Order Summary:

CLIN Supplies/Services Qty Unit Unit Price Amount

0001 Equipment - Amount 80%- DIGITAL DIAGNOST 1 EA $267,118.22 $267,118.22

0002 Equipment - Amount 20% and Professional Services 1 EA $66,779.56 $66,779.56

0003 Extended Installation 1 EA $150,547.00 $150,547.00

0004 Training 1 EA $3,751.00 $3,751.00

0005 Training 2 EA $8,680.00 $17,360.00

0006 Training 2 EA $4,340.00 $8,680.00

Delivery Order Total: $514,235.78

Notes:

The Equipment pricing and configuration is in accordance with QUOTE 1-VZKBU5 R7 dated 8/6/2013.

Only expanded equipment descriptions are incorporated by reference into this delivery order.

Government contract terms and conditions supersede quotation terms and conditions.

For purposes of delivery, acceptance, and payment, CLIN 0001 and CLIN 0002 are based upon an 80%/20% split of the System amount. For CLIN 0001, 80% is payable upon physical delivery of the system as listed. For CLIN 0002, 20% is payable upon successful completion of the installation and government acceptance testing.

PHILIPS agrees to comply with the Air Force’s Information Assurance (IA) requirements as identified as “Air Force Information Assurance Requirements – Version 1.0 (May 2013)” included in this delivery order.

Ship to Address:

FM4800

73 Nealy Avenue Building 256 Langley AFB, Virginia 23665 2079 Mark For:

FX7059-3227-G001

LAN10-0007

633rd Medical Group

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0001 Equipment - Amount 80% - DIGITAL DIAGNOST 1 EA $267,118.22 $267,118.22

Catalog no. Description Qty. Unit NNAH275 Digital Diagnost 1 EA NRDN160 Digital TH Table Fixed Detect. 1 EA NRDN058 Digital VS Ext. Fixed Detector 1 EA NRDN302 Generator 80KW 1 EA NRDN092 High Power X-Ray Tube 1 EA NRDN140 CS and table tray motorization 1 EA

NRDN146 UPS 1 EA

NRDN150 Wide Tabletop 1 EA NRDN153 2nd controler for TH/TF table 1 EA NRDN175 Motorized Tilting of VS Stand 1 EA NRDN178 Spacer for VS Vertical Stand 1 EA NRDN199 Adapt. Transf. 415-480 V 1 EA NRDN221 Rails Extension CS 1 EA NRDN222 Rails Separation CS 1 EA NDCC061 DICOM Communication Package 1 EA NDCC221 Clinical QC 1 EA 989001001622 CS Rails Extension 2,7 m (8' 10.3") 1 EA 989001084241 Stretch grip for VS/VM stand 1 EA 989001085351 Remote control holder 1 EA

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0002 Equipment - Amount 20% and Professional Services 1 EA $66,779.56 $66,779.56

Catalog no. Description Qty. Unit Installation of Equipment in CLIN0001

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0003 Extended Installation 1 EA $150,547.00 $150,547.00

Catalog no. Description Qty. Unit SP006 Turnkey Operation 1 EA

PHILIPS shall furnish design plans, labor, materials, and equipment necessary to provide for installation, in accordance with the “Pre- Installation Site Survey” to accommodate the above diagnostic system. Extended Installation shall include, as a minimum, connecting with adequate utilities and furnishing and installing support structures for above system. In addition to the above, the Extended Installation shall include all work identified in PHILIPS’s Extended Installation Proposal Digital Diagnost TH Room 1216 dated 8/6/2013 (copy attached).

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0004 Training 1 EA $3,751.00 $3,751.00

Catalog no. Description Qty. Unit 989801292145 XR Add OnSite Clin Educ 16h 1 EA

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0005 Training 2 EA $8,680.00 $17,360.00

Catalog no. Description Qty. Unit

989801299992 XD3605DIGITALDIAGNOSTR2/R3CTC9 1 EA

CLIN SUPPLIES/SERVICES QTY UNIT UNIT PRICE AMOUNT

0006 Training 2 EA $4,340.00 $8,680.00

Catalog no. Description Qty. Unit 989801299949 XD3671C Bio BUCKY DIAGNOST PartII CTC 5 1 EA

Delivery/Inspection/Acceptance Schedule:

CLIN Supplies/Services Inspection/Acceptance Completion Milestone 0001 Equipment - Amount 80% Destination 90 Days After Date of Order 0002 Equipment - Amount 20% and

Professional Services Destination 120 Days After Date of Order

0003 Extended Installation Destination 120 Days After Date of Order 0004-0006 Training Destination 365 Days After Date of Order

*Note: "Contractor must submit an “Other/Other Receiving Report (RR) only” into the Wide Area Workflow (WAWF) system for inspection and acceptance prior to submitting an invoice. If you are not subscribed to the WAWF system and/or need instruction on how to submit a RR for DLA TROOP SUPPORT Medical Capital Equipment, please contact the contracting specialist identified in block 6 of this order."

Important WAWF Codes for Other/Other Receiving Report:

Pay Office: SL4701 Admin By = Issue By = Inspect By = Accept at Other = SPM2D1 Ship to: FM4800 (Use SPM2D1 only if this code does not work)

Notification of Installation Completion and Readiness for Inspection Testing:

PHILIPS shall send an official e-mail Notification of Installation Completion and Readiness for Inspection Testing to the following Government e-mail addresses. The Government shall have 30 calendar days to complete the Inspection Testing from the date of the e-mail notification. The subject line of this e-mail shall be “Installation Completion – Readiness for Inspection Testing Notification”.

This e-mail shall include the following as a minimum:

Complete contract number.

Description of the equipment.

The Installation Location (Hospital/Facility Name, Room # & Base/City/State).

Notification POC information: Name, title, telephone # and e-mail address.

PHILIPS’s Inspection POC: Name, title, telephone # and e-mail address.

The following is the Government’s e-mail notification list for this Delivery Order:

devang.patel@dla.mil adam.landeroz@detrick.af.mil andrew.taylor@langley.af.mil afmoa.sgals.capitalequipment@detrick.af.mil

An automated WAWF receiving report submission notification is not sufficient for the above notification requirement.

Points of Contact

LANGLEY AFB, VA

Requisition POC Ms. Joann Halloran 301-619-4163 joann.halloran@detrick.af.mil

Technical POC

AFMOA SGAL

301-619-6872 afmoa.sgals.capitalequipment@detrick.af.mil

Shipping/Receipt POC SrA Andrew Taylor 757-764-9764 andrew.taylor@langley.af.mil

Inspection/Acceptance Testing POC SSgt Adam Landeroz 301-619-9061 adam.landeroz@detrick.af.mil

IT Dept POC IA PMO Office 301-619-9081 afmoa.sgale.mdpmo@detrick.af.mil

DLA Troop Support – Medical Supply Chain

Project Engineer/WAWF Inspector Devang Patel 215-737-3137 devang.patel@dla.mil

Air Force Information Assurance Requirements – Version 1.0 (May 2013)

In accordance with Department of Defense Directive (DoDD) 8500.01E, all acquisitions of Automated Information Systems (AIS) to include, outsourced IT-based processes, and platforms or weapon systems with connections to the Global Information Grid (GIG) must be certified and accredited. The primary methodology for certifying and accrediting Department of Defense (DoD) information systems is the DoD Information Assurance Certification and Accreditation Process (DIACAP) of DoD Instruction (DoDI) 8510.01 and is applicable to all DoD owned or Air Force (AF) controlled information systems that receive, process, store, display or transmit DoD information, regardless of Mission Assurance Category (MAC) classification or sensitivity, except, per DoDD 8500.1 Paragraph 2.3; IT that is considered Platform Information Technology (PIT).

Vendor must subscribe to Office of Personnel Management (OPM) National Agency with local Agency and Credit (NACLC) for vendor personnel required to log-onto any systems connected to the MTF/DoD network. This applies to any vendor personnel accessing the DoD networked device on-site or remotely and during installation.

The Vendor shall comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (P.L. 104-191) requirements, specifically the administrative simplification provisions of the law and the associated rules and regulations published by the Secretary, Health and Human Services (HHS). This includes the Standards for Electronic Transactions, the Standards for Privacy of Individually Identifiable Health Information and the Security Standards.

If an Authorization to Connect (ATC) and/or an Authorization to Operate (ATO), approval has not already been granted for the product version/system awarded on this specific contract, vendor will comply with the following timeline:

Within 30 days of contract award or issuance of a delivery order – contact Air Force Medical Service (AFMS) Program Management Office (PMO) to obtain C&A requirements and templates required for IA submission process. The PMO can be reached at afmoa.sgale.mdpmo@detrick.af.mil.

Within 60 days of contract award or issuance of a delivery order – if not done already, send completed templates and required documents to AFMS PMO point of contact obtained from above action. After submission of these documents, any missing information or information requested by the AFMS PMO must be submitted within 30 days to continue to the C&A process.

If an ATC, and/or an ATO, has already been granted for this specific equipment, vendor must submit a copy of the approval within 30 days of contract award or issuance of a delivery order.

If the vendor does not comply with the timeline provided above, the Government reserves the right to cancel this contract/delivery order at no cost to the Government. The Vendor is required to maintain its ATC/ATO for the life expectancy of the equipment or as long as the AF is in possession of the equipment, whichever is longer. The Vendor shall renew C&A requirements for the equipment/system prior to the expiration of the ATC/ATO.

References:

Public Law 100-235 Public Law 107-347

CJCSI 6212.01B

CJCSM 6510.01

DODD 8500.01E

DODI 8500.2

DODI 8510.01

DODI 5200.1-R

DODI 5200.2

HIPAA, AFI33-210

DOD IPv6 Standard Profiles for IPv6 Capable Products, and Defense Information Systems Agency (DISA) – http://www.disa.mil