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Section B. Section B. Document Transcript

  • Naval Medical Logistics Command AJ-01-09 NOTICE OF CONTRACTING OPPORTUNITY APPLICATION FOR NAVY CONTRACT POSITIONS Radiologist/Naval Hospital Great Lakes, IL REQUIREMENTS PACKAGE- AJ-01-09 17 May 09 THIS IS NOT A CIVIL SERVICE POSITIONI. IMPORTANT INFORMATION: CUTOFF DATE AND TIME FOR RECEIPT OF APPLICATIONS IS 3:00PM EST ON OR BEFORE FRIDAY, 29 MAY 2009. SEND APPLICATIONS TO THE FOLLOWINGADDRESS:NAVAL MEDICAL LOGISTICS COMMANDATTN: CODE 024J693 NEIMAN STREETFORT DETRICK, MD 21702-9203E-MAIL: Acquisitions@med.navy.milIN SUBJECT LINE REFERENCE: “CODE 024J”A. NOTICE. This position is set-aside for an individual RADIOLOGIST only. Applications from companies willnot be considered; additionally, applications from active duty Navy personnel, civilian employees of the Navy, orpersons currently performing medical services under other Navy contracts will not be considered without the priorapproval of the Contracting Officer.B. POSITION SYNOPSIS. RADIOLOGIST. The Government is seeking to place under contract an individualwho possess and maintain a current, unrestricted license to practice medicine in any one of the fifty States, theDistrict of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.. This individual mustalso (1) meet all the requirements contained herein; (2) be eligible for clinical privileges and (3), competitively winthis contract award (See Sections D and E).Services shall be provided in the Naval Hospital Great Lakes, IL. Future references to Military Treatment Facility(MTF) refers to the Naval Hospital Great Lakes.You shall normally provide services Monday through Friday for an 8.5 hour shift (to include an uncompensated .5hour for lunch) from 0800 to 1630 (8 A.M. to 4:30 P.M.). The normal duty hours shall not exceed 160 hours per 4-week period. You shall normally not be required to provide services on Federal Holidays or when an executiveorder is issued by the President of the United States, with the exception of providing on-call services which mayoccur on a holiday. You shall be compensated by the Government for these periods of authorized absence.On-call services: Additionally, the HCW shall share general radiology call coverage with other departmentalradiologist. These services shall include performance or direct supervision of emergent diagnostic and therapeuticradiological procedures. On-call services begin at the end of the normal workday (e.g., 1630 hours) during the workweek and shall continue until the commencement of the following workday (0800 hours). Weekend coveragebegins at the close of the workday Friday until commencement of the workday Monday, unless the weekendincorporated a holiday on a Monday or Friday. In case of a 3-day weekend of this type, call coverage extend fromclose of the preceding workday until the beginning of the first following workday. The HCW shall normallyprovide general radiology call for up to 4 days a month. Historical data indicates that the on-call physician respondsto an average of up to1.2 calls to cover Saturday morning clinic. Calls requiring that the physician present to themedical facility occur on an average of 1 occasion per on-call. On-call service requirements are variable and depend 1
  • Naval Medical Logistics Command AJ-01-09on the current level of radiologist staff and their availability to share on-call services. The on-call schedule will beprovided 1 month in advance.For the provision of on-call services, you will be assigned a cellular phone or a beeper and a laptop computer (orequivalent), furnished by the Government. You are responsible for replacement costs if the beeper, cell phone, orlaptop computer is lost or damaged through negligence. If paged, the you shall respond by telephone within 30minutes to the MTF. Depending upon the nature of the on-call request, you will either be required to report to theMTF, or stand–by at home to receive, interpret, and report on radiographic images transmitted via laptop computer.You shall accrue 10 hours of personal leave for every 80 hours worked. At the discretion of the CommandingOfficer, up to 40 hours of accrued leave may be carried over from one fiscal year to the next, as long as the balancecarried over is used by 31 December of that same calendar year. This contingency for leave carry over does notapply if the following option period is not exercised by the Government or during the last option year of thecontract. You shall be compensated by the Government for these periods of planned absence. This position is for aperiod beginning from the start date through 30 September of the same fiscal year with options to extend thecontract for a total of five years. The contract will be renewable each fiscal year at the option of the Navy.II. STATEMENT OF WORKA. The use of “Commanding Officer” means: Commanding Officer, Naval Hospital Great Lakes, IL or designatedrepresentative, e.g. Technical Representative, Technical Liaison, or Department Head.B. SUITS ARISING OUT OF MEDICAL MALPRACTICE. You will be serving at the military treatment facilityunder a personal services contract entered into under the authority of section 1091 of Title 10, United States Code.Accordingly, section 1089 of Title 10, United States Code shall apply to personal injury lawsuits filed against youbased on negligent or wrongful acts or omissions incident to performance within the scope of this contract. You arenot required to maintain medical malpractice liability insurance. In the event of a claim or lawsuit relating to yourperformance of duties under this contract, the parties shall follow the procedures established in SECNAVINST6300.3A, a copy of which can be viewed at https://doni.daps.dla.mil/SECNAV.aspx.By providing services under this contract you shall be rendering personal services to the Government and shall besubject to day-to-day supervision and control by Government personnel. Supervision and control is the process bywhich you receive technical guidance, direction, and approval with regard to a task(s) within the requirements of thiscontract.C. DUTIES AND RESPONSIBILITIES.1. Clinical Duties. You shall perform a full range of Radiologist services, within the scope of clinical privilegesgranted by the Commanding Officer, on site using government furnished facilities, supplies and equipment andcomplying with the MTFs applicable Standard Operating Procedures (SOPs) and clinical guidelines. Workloadoccurs as a result of either scheduled or unscheduled requirements for care. You are responsible for a full range ofdiagnostic examinations, the development of comprehensive treatment plans when indicated, delivery of treatmentwithin the personnel and equipment capabilities of the treatment facility, provision of mandated medical surveillanceand preventive services, and the quality and timeliness of treatment records and reports required to documentprocedures performed and care provided. You shall refer patients to staff specialists for consultation opinions andcontinuation of care and shall see the patients of other government staff health care providers who have beenreferred for consultation and treatment. Your productivity is expected to be comparable to that of other Radiologistsassigned to the same facility and authorized the same scope of practice.1.2.Provide consultation, diagnostic work-up planning, radiation monitoring, performing and interpreting thefollowing procedures: Intravenous pyelograms; Upper GI series; Small bowel follow-through; Barium enemas;Ultrasounds; Computed Tomography; Mammography; Nuclear Medicine; IVP performed by Urology, or Radiology;Breast Needle localization; Ultrasound guided biopsy; Ultrasound guided drainage; CT guided biopsy; CT guideddrainage; CT and venograms. Magnetic Resonance Imaging (MRI) interpretation shall be performed at the time ofdepartment staffing by 5 individuals. Stereotactic Breast biopsy shall be performed when equipment is madeavailable. 2
  • Naval Medical Logistics Command AJ-01-091.3. Prescribe and dispense medications as delineated by the Pharmacy and Therapeutics Committee.1.4 Promote preventive and health maintenance care, including annual physicals, positive health behaviors, andself-care skills through education and counseling.1.5 Participate in clinical investigations.1.6. Refer patient appropriate to their need. Receive referrals from other members of the healthcare team.1.7. Use the CHCS system to enter orders and prescriptions; retrieve test results; request specialty consultations;and correspond via E-mail. Utilize the ADM module of CHCS for workload data collection, capturing ICD-9,E&M, and CPT-4 codes.1.8. Become familiar with the Department of Defense TRICARE Program and the methodology to function therein.2. Administrative Duties. Perform a wide range of administrative duties related to clinical practice. These include,but are not limited to, performance improvement and quality assurance functions, family advocacy activities,attending meetings, using computer and paper systems to document and report patient care and workload,participating in education activities, attending in-service and orientation training, maintaining HIPAA compliance,maintaining JCAHO compliance, safety activities, participating in emergency preparedness and other drills, andeconomical use of supplies and equipment.2.1. Participate in peer review and performance improvement activities.2.2. Demonstrate appropriate delegation of tasks and duties in the direction and coordination of health care teammembers, patient care, and clinic activities.2.3. Participate in meetings to review and evaluate the care provided to patients, identify opportunities to improvethe care delivered, and recommend corrective action when problems exist. Should a meeting occur outside of theHCW’s regular working hours, the HCW shall be required to read and initial the minutes of the meeting.2.4. Participate in the provision of in-service training to clinic staff members and other staff working under theHCW’s cognizance.2.5. Participate in the provision of in-service training to members of the clinical and administrative staff on subjectsgermane to medical care and attend annual renewal of the following Annual Training Requirements provided byMTF: family advocacy, disaster training, infection control, Sexual Harassment and Bloodborne Pathogens.2.6. Participate in the implementation of the Family Advocacy Program as directed. Participation shall include, butnot be limited to, appropriate medical examination, documentation and reporting.2.7. Attend Composite Health care System (CHCS)/Armed Forces Health Longitudinal Technology (AHLTA)training provided by the Government for a minimum of four (4) hours, and up to a maximum of 40 hours.2.8. Attend all annual training classes required by this command.2.9. Comply with the standards of the Joint Commission, applicable provisions of law and the rules and regulationsof any and all Governmental authorities pertaining to licensure and regulation of health care personnel and medicaltreatment facilities, the regulations and standards of medical practice of the MTF and the bylaws of the hospitalsmedical staff. Adhere to and comply with all Department of the Navy, Bureau of Medicine and Surgery and localClinic instructions and notices that may be in effect during the term of the contract.2.10. Comply with the HIPAA (Health Insurance Portability and Accountability Act) privacy and security policiesof the treatment facility. Providers shall obtain/maintain a National Provider Identifier (NPI) in accordance withDOD and MTF policy/instruction. 3
  • Naval Medical Logistics Command AJ-01-092.11. The HCW shall participate in executing the Emergency Preparedness Plan (drills and actual emergencies) asscheduled by the MTF (typically semiannually). A MTF personnel re-call list with personal contact information forall military, civil service and contract employees is required to prepare in advance for an actual emergency. TheHCW shall provide personal contact information to the designated supervisor upon commencement of services.Should an emergency occur, the HCW shall be contacted with shift information and for accountability purposes.3. Credentialing Requirements:3.1. Upon award, you shall complete an Individual Credentials File (ICF) prior to performance of services. Thecompleted ICF must be forwarded 30 days prior to performance of duties to the MTF’s Medical Staff ServicesProfessional. The ICF, maintained at the MTF, contains specific information with regard to qualifying degrees andlicenses, past professional experience and performance, education and training, health status, and currentcompetence as compared to specialty-specific criteria regarding eligibility for defined scopes of health care services.BUMED Instruction 6320.66E, Section 4 and Appendices B and R detail the ICF requirements. BUMEDINST6320.66E is available at http://navymedicine.med.navy.mil/default.cfm?selTab=Directives. Click BUMEDDirectives, select page 4 of the directives, and scroll down to the instruction number. The instruction is nowcontained in several separate files.3.2. If during the Governments evaluation of the ICF a negative current clinical competency assessment isdetermined, it will bring the MTF’s consideration of your application for credentialing/privileging to an immediateclose. Since granting credentialing/privileging is required as a condition of your employment under the contractresulting from this Notice, then the contract will provide that a negative current clinical assessment will result in theissuance of a contract termination notice by the contracting officer under the clause at FAR 52.249-12.3.3. If clinical privileges have been summarily suspended or are being held in abeyance (per BUMEDINST6320.66E (or latest version)), pending an investigation into questions of professional ethics or conduct, performanceunder this contract may be suspended until clinical privileges are reinstated. No reimbursement shall be made andno other compensation shall accrue to you so long as performance is suspended or clinical privileges are held inabeyance. The denial, suspension, limitation, or revocation of clinical privileges based upon practitioner impairmentor misconduct will be reported to the appropriate licensing authorities of the state in which the license is held IAWBUMEDINST 6320.66E (or latest version) and BUMEDINST 6320.67A CH01.4. Background Investigations. By fulfillment of this position, you will have access to Department of Navy (DON)IT systems and/or perform IT-related duties with varying degrees of independence, privilege and/or ability to accessand/or impact sensitive data and information. Additionally you may have contact with patients under the age of 18.Therefore, you shall be subject to Information Technology (IT)/Sensitive Information (SI) security requirementswhich include national and local background checks and a credit check in accordance with Secretary of Navy(SECNAV) Manual 5510.30, as well as a criminal background check in accordance with the Crime Control Act of1990. It should be noted that in order to receive access to the DON IT system(s) and the sensitive data necessary toperform the duties for this position, you must be a U.S. citizen. You shall be required to complete the paperworknecessary for the Government to complete the background investigations.D. MINIMUM PERSONAL QUALIFICATIONS. To be qualified for this position you must:1. Possess a Doctorate Degree in Medicine from an accredited college approved by the Liaison Committee onMedical Education and Hospitals of the American Medical Association, a Doctorate Degree in Osteopathy from acollege accredited by the American Osteopathic Association, or permanent certification by the EducationalCommission for Foreign Medical Graduates (ECFMG) or have completed the Fifth Pathway. Canadian practitionerswho have graduated from an accredited Canadian medical school, and hold a Licentiate of the medical Council ofCanada, are accepted as equivalent to the Accreditation Council for Graduate Medical Education (ACGME)accredited graduate trained in a U. S. Hospital. They may apply and be granted core or supplemental privilegesupon receipt of a State license.2. Posses a minimum of 1900 hours of work experience per year since completion of a training program inresidency Diagnostic Radiology approved by the Accreditation Council for Graduate Medical Education or the 4
  • Naval Medical Logistics Command AJ-01-09Committee on Postdoctoral Training of the American Osteopathic Association or those Canadian training programsapproved by the Royal College of Physicians and Surgeons of Canada or other appropriate Canadian medicalauthority.- AND -Completion of a fellowship in any of the following: Body imaging, Breast Imaging, Bone or Chest Imaging,Neuroradiology, or Interventional Radiology and perform at least 30 hours of radiology work experience per weeksince completing the Fellowship.- OR-Possess and maintain board certification in Diagnostic Radiology by the American Board of Radiology or by theAmerican Osteopathic Board of Radiology- AND-Completion of at least 100 hours of continuing education within the two years preceding the date set for receipt ofproposal which maintains skill and knowledge as a Radiologist. Meet all requirements set forth by the FDAin 21 CFR Part 900 to be qualified to required mammograms in accordance with the mammography QualityStandards Act (MQSA), to included having read a minimum of 960 mammograms within the preceding 2 years.3. Possess and maintain a current, unrestricted license to practice medicine in any one of the fifty States, the Districtof Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.4. Possess and maintain certification in Basic Life Support (BLS) prior to commencement of services.5. Possess experience as a radiologist of at least 24 consecutive months, post residency, within the preceding36 months.6. Possess and maintain current certification in American Heart Association Basic Life Support (BLS) for HealthCare Providers; American Heart Association Health Care Provider course; American Red Cross CPR (CardioPulmonary Resuscitation) for the Professional Rescuer; or an equivalent MTF course. Practitioners, not currently inpossession of current certification, must acquire certification prior to initiating contract performance. Web basedclasses do not meet these standards. A copy of the BLS instruction may be obtained from the World Wide Web at:http://navymedicine.med.navy.mil/Files/Media/directives/1500-15a.pdf.7. Submit two letters of reference written within the last two years attesting to the healthcare worker’s clinicalskills. A minimum of one of the letters must be from a physician supervisor (allopathic or osteopathic). The otherletter must be from either clinic or hospital administrators, or practicing physicians (allopathic or osteopathic).Reference letters shall attest to the healthcare worker’s communication skills and ability to relate to patients as wellas professional and other interpersonal skills among staff members and must include name, title, phone number, dateof reference, address and signature of the individual providing reference. These letters are in addition to the lettersof clinical competency mentioned below in D.8.8. Possess current clinical competency, as defined in section 5 of BUMEDINST 6320.66E(http://navymedicine.med.navy.mil/default.cfm?selTab=Directives), in the clinical discipline required by thiscontract (e.g., physician, RN, dentist). Officials from the medical treatment facility (MTF) where your contractservices will be performed will exercise their medical judgment when assessing whether your professional skill setand clinical practice history satisfy the indicia of current clinical competency that are specified in this instruction.To enable this assessment to be made, you shall submit two letters of reference from supervisors attesting to yourpersonal clinical experience and professional skills as a practitioner in your discipline. These letters must be datedand shall include the name, title, phone number, address and signature of the individual providing the reference.The letters must have been written within the 2 years preceding submission of your proposal.9. Represent an acceptable malpractice risk to the Navy. 5
  • Naval Medical Logistics Command AJ-01-0910. Be in good standing and under no sanction or suspension listing by the Federal Government.11. Possess U.S. citizenship which is necessary to gain access to DON IT systems and sensitive information (seeSection C, paragraph 4.).12. If awarded a contract, you will be required to obtain a physical examination and immunizations at your ownexpense prior to initiation of contract performance. Currently practicing NHGL Radiologists are excluded from thisrequirement. The requirements are provided on the HEALTH EXAMINATION ANDIMMUNIZATION/SCREENING REQUIREMENT FORM, the current version of which is available athttp://www.nmlc.med.navy.mil/handbooks/Physical%20Exam%20and%20Immunization%20Form.pdf.E. Factors to be used in a Contract Award Decision. If you meet the minimum qualifications listed in the paragraphabove entitled, "Minimum Personnel Qualifications" you will be ranked against all other qualified candidates usingthe following criteria, (listed in descending order of importance). The "Personal Qualification Sheet", letters ofrecommendation, letters of clinical competency, continuing medical education hours, and, if you have prior militaryservice, the Form DD214, shall be used to evaluate these items.1. The Government will consider the letters reference required in items D.7. and D.8. above. Those letters mayenhance your ranking if they substantively address items such as clinical skills, professionalism, or specific areas ofexpertise, etc. Letters which are supported by attached copies of positive clinical evaluations or reports ofpractitioner-specific data and information generated by organizational quality management activities will enhancethe rating.2. Experience, in excess of the minimum required experience, in positions relevant to the qualifications and dutiesof the contract position. The Government will evaluate the quantity, currency, quality, and relevancy of theexperience based on the information you provide in the Personal Qualifications Statement, and the letters ofrecommendation or other supporting documentation you submit. The Government may contact the authors of thereference letters (verified contact information must be provided).3. Total Radiologist specific continuing medical education hours obtained within the preceding 2 years.F. Instructions for Completing the Application. To be qualified for this contract position, you must submit thefollowing:1. _____ A completed “Personal Qualifications Sheet” (Attachment I)2. _____ A completed Pricing Sheet (Attachment II)3. _____ Proof of citizenship requirements (Attachment III) Please submit copies with your application. If you areawarded a contract , you will be required to present originals upon check-in.4. _____ Central Contracting Registration Confirmation Sheet (Attachment IV)5. _____ Proof of Small Business Representation (Attachment V)6. _____ Four letters of reference per paragraphs D.7. and D.8. above.7. _____ Physical certification requirements (only if awarded with contract) per paragraph D.12. above.G. OTHER INFORMATION FOR OFFERORS.The ISA HANDBOOK is available at http://www.nmlc.med.navy.mil/handbooks/ISA%20Handbook%202006%20Final.doc . Under “Doing Business With Us,” select Individual Set-Asides, OR request it from thecontract specialist listed below.After your application is reviewed, the Government will do at least one of the following: (1) Call you to negotiateyour price, or (2) Ask you to submit additional papers to ensure you are qualified for the position, (3) Send you aletter to tell you that you are either not qualified for the position or that you are not the highest qualified individual,or (4) Make contract award from your application. If you are the successful applicant, the contracting officer willmail to you a formal government contract for your signature. This contract will record the negotiated price, yourpromise to perform the work described above, how you will be paid, how and by whom you will be supervised, and 6
  • Naval Medical Logistics Command AJ-01-09other rights and obligations of you and the Navy. Since this will be a legally binding document, you should reviewit carefully before you sign.Upon notification of contract award, you will be required to obtain a physical examination at your expense. Thephysician must complete the questions in the physical certification, which will be provided with the contract. Youwill also be required to obtain the liability insurance specified in Attachment 2, Pricing Information. Beforecommencing work under a Government contract, you must notify the Contracting Officer in writing that the requiredinsurance has been obtained.A complete, sample contract is available upon request.Questions concerning this package may be addressed at (301) 619-8421.We look forward to receiving your application. 7
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT I PERSONAL QUALIFICATIONS SHEET (PQS) – RADIOLOGIST1. Every item on the Personal Qualifications Sheet must be addressed. Please sign and date where indicated. Anyadditional information required may be provided on a separate sheet of paper (indicate by number and section thequestion(s) to be addressed).2. The information provided will be used to determine acceptability based on Section D of the Notice ofContracting Opportunity. In addition to the Personal Qualifications Sheet, submit two letters of reference asdescribed in Section D.7 and two letters of clinical competency as described in Section D.8 and Items X and XI ofthis Sheet.3. After contract award, all of the information provided will be verified during the credentialing process. At thattime, you will be required to provide the following documentation verifying your qualifications: ProfessionalEducation Degree, Release of Information, Personal and Professional Information Sheet for Privileged Providers, allmedical licenses held within the preceding 10 years, continuing education certificates, and U.S. citizenshipdocumentation. If you submit false information, the following actions may occur:a) Your contract may be terminated for default. This action may initiate the suspension and debarment process,which could result in the determination that you are no longer eligible for future Government contracts.b) You may lose your clinical privileges. If that occurs, an adverse credentialing action report will be forwarded toyour State licensing bureau and the National Practitioners Databank.4. Health Certification. Individuals providing services under Government contracts are required to undergo aphysical exam and possible immunizations 60 days prior to beginning work. The exam is not required prior toaward but is required prior to the performance of services under contract. By signing this form, you haveacknowledged this requirement. (Section D, Item 10)5. Personal and Practice Information: (Section D, Items 9 and 10) Yes No 1. Have you ever been the subject of a malpractice claim? ___ ___ (indicate final disposition of case in comments) 2. Have you ever been a defendant in a felony or misdemeanor case? ___ ___ (indicate final disposition of case in comments) 3. Has your license to practice or DEA certification ever been revoked ___ ___ or restricted in any state? 4. Have you ever been arrested for or charged with a crime involving a child? ___ ___ 5. a. Are you a U.S. Citizen? ___ ___ b. If yes, do you hold dual citizenship or a passport from a foreign country? ___ ___If any of questions 1 through 4 and 5b above is answered "yes" attach a detailed explanation. Specifically addressthe disposition of the claim or charges for numbers 1 through 4 above, and the State of the revocation for number 3above. If you hold a dual citizenship or have a passport issued from a foreign country, address which country thedual citizenship is held and/or which foreign country has issued you a passport. 8
  • Naval Medical Logistics Command AJ-01-09PRIVACY ACT STATEMENTUnder 5 U.S.C. 552a and Executive Order 9397, the information provided on this page and the Personal QualificationsSheet is requested for use in the consideration of a contract; disclosure of the information is voluntary; failure to provideinformation may result in the denial of the opportunity to enter into a contract. _________________________ _____________(mm/dd/yy) (Signature) (Date) 9
  • Naval Medical Logistics Command AJ-01-09I. General InformationName: SSN:______________ Last First MiddleDate of Birth: ___________Address: ___________________________________ ___________________________________ ___________________________________Phone: ( ) ________________ Email: ________________________Medical Information YES NO1. Do you have any physical or mental impairment thatcould limit your clinical practice? ___ ___2. Have you been hospitalized for any reason duringthe past 5 years? ___ ___3. Are you currently receiving or have you ever receivedformal mental health therapy or treatment? ___ ___4. Are you currently receiving, or have you in the pastever received, treatment or therapy for any alcohol ordrug-related condition? ___ ___5. Have you ever been unlawfully involved in the use ofcontrolled substances? ___ ___If any of questions 1 through 5 above is answered, "yes”, attach a detailed explanation.Professional EducationA. Doctorate Degree (Section D, Item 1):a. Name of Accredited School: Date of Training (From) (To)_________________________________ ______ ______b. Type of Degree:_____________________________________c. Location and Address of School:__________________________________________________________________________________________________________________________________________II. Board certification in Diagnostic Radiology by the American Board of Radiology or by the AmericanOsteopathic Board of Radiology OR completion of a fellowship (Section D, Item 2.1 and 2.2):___________________________ ____________________Title of Certification Date of Certification (mm/dd/yy)___________________________ _____________________Fellowship Date of Completion (mm/dd/yy) 10
  • Naval Medical Logistics Command AJ-01-09III. Professional Employment (Factor for Award): List your current and preceding employers. Provide dates asmonth/year. (Section D, Item 2)Name and Address of Present Employer From To(1) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ From To(2) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ From To(3) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ From To(4) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ From To(5) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ From To(6) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you are currently employed on a Navy contract? If so where is your current contract and what is the position?___________________________________________When does the contract expire? _____________________________________IV. State Professional Licensure (License must be current, valid, and unrestricted) (Section D, Item 3): ________ (State) Date of Expiration: _____________ (mm/dd/yy) ________ (State) Date of Expiration: _____________ (mm/dd/yy) ________ (State) Date of Expiration: _____________ (mm/dd/yy)V. Reserved. 11
  • Naval Medical Logistics Command AJ-01-09VI. Reserved.VII. I am currently certified in BLS or will be certified in BLS prior to contract start-date. (Section D, Item 3) YES_____________ NO _____________VIII. Reserved.IX. Continuing Education Hours within the preceding 2 years (Factor for Award) (Section D, Item 2 and Section E,Item 3):Title of Course From To CE Hours________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________X. Professional Reference (Section D, Item 7)Provide two letters of reference attesting to your personal clinical experience and professional skills as a practitionerin your discipline. A minimum of one of the letters must be from a physician supervisor (allopathic or osteopathic).The other letter must be from either clinic or hospital administrators, or practicing physicians (allopathic orosteopathic). Reference letters shall attest to the healthcare worker’s communication skills and ability to relate topatients as well as professional and other interpersonal skills among staff members and must include name, title,phone number, date of reference, address and signature of the individual providing reference. These letters are inaddition to the letters of clinical competency mentioned in Section D.5.XI. Clinical Competency References (Section D, Item 8)Provide two letters of reference two letters of reference from supervisors attesting to your personal clinical experienceand professional skills as a practitioner in your discipline. These letters must be dated and shall include the name,title, phone number, address and signature of the individual providing the reference. The letters must have beenwritten within the 2 years preceding submission of your proposal.XII. Additional Information:Provide any additional information you feel may enhance your ranking based on Section E. Factors to be used in aContract Award Decision, such as your resume, curriculum vitae, commendations or documentation of any awards youmay have received, etc.I hereby certify the above information to be true and accurate: (mm/dd/yy) (Signature) (Date) ________________________________ Name (Printed) 12
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT II PRICING SHEETPERIOD OF PERFORMANCEServices are required from 01 October 2009 through 30 September 2010. The Contracting Officer reserves the rightto adjust the start and end dates of performance to meet the actual contract start date. Services may also be extendedby exercise of Option Periods.PRICING INFORMATION (a) Hourly Rates: Insert the price per hour that you want the Navy to pay you. You may want to consider inflationrates when pricing the option period. The Government will award a contract that is neither too high nor too low.Your price would be high enough to retain your services but not so high as to be out of line when compared to thesalaries of other Radiologists in the Great Lakes, IL area. Please note that if you are awarded a Government contractposition, you will be responsible for paying all federal, state and, local taxes. The Navy does not withhold anytaxes. Your proposed prices should include the amount you will pay in taxes. (b) Liability Insurance: Before commencing work under a contract, you shall obtain the following required levelsof insurance at your own expense: (a) General Liability - Bodily injury liability insurance coverage written on thecomprehensive form of policy of at least $500,000 per occurrence, and (b) Automobile Liability - Auto liabilityinsurance written on the comprehensive form of policy. Provide coverage of at least $200,000 per person and$500,000 per occurrence for bodily injury and $20,000 per occurrence for property damage. (c) Limitation of Payment for Personal Services: Under the provisions of 10 U.S.C 1091 and Department ofDefense Instruction (DODI) 6025.5, "Personal Services Contracting" implemented 6 January 1995, the total amountof compensation paid to an individual direct health care provider in any year cannot exceed the full time equivalentannual rate specified in 3 U.S. C. 102. (d) Price Proposal:Line Item Description Quantity Unit Unit Price Total Amount0001 The offeror agrees to perform, on behalf of the Government, the duties of one Full Time Radiologist at Naval Health Clinic Great Lakes, IL in accordance with this Application and the resulting contract.0001 Base Period: 01 Oct 09 through 30 Sep 10 2,088 HRS $______ $ _________1001 Option Period I: 01 Oct 10 through 30 Sep 11 2,088 HRS $______ $ _________2001 Option Period II: 01 Oct 11 through 30 Sep 12 2,096 HRS $______ $ _________3001 Option Period III: 01 Oct 12 through 30 Sep 13 2,088 HRS $______ $ _________4001 Option Period IV: 01 Oct 13 through 30 Sep 14 2,088 HRS $______ $ _________Printed Name ___________________________________________Signature ___________________________________________ Date ________________ 13
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT III PROOF OF CITIZENSHIP REQUIREMENTSExcerpt from SECNAV M-5510.30 of June 2006, Appendix F. For a full copy of the Manual gohttp://doni.daps.dla.mil/SECNAV%20Manuals1/5510.30.pdf.4. All documents submitted as evidence of U. S. citizenship must be original documents or certified copies.Uncertified copies are not acceptable. The following documents are acceptable proofof citizenship:a. The original U. S. birth certificate with a raised seal issued at the time of birth from one of the 50 states, oroutlying territories or possessions.b. A hospital birth certification (clinic and commercial birth center certification is not permitted) with anauthenticating raised seal or signature provided all vital information is given.c. A delayed birth certificate provided it shows the birth record was filed within one year after birth, it bears theregistrars seal and signature, and cites secondary evidence such as a baptismal certificate, certificate ofcircumcision, affidavits of persons having personal knowledge of the facts of the birth or other official records suchas early census, school or insurance.d. U.S. Passport (current or expired) or U.S. passport issued to individual’s parent in which the individual isincluded.e. FS-240 Report of Birth Abroad of a Citizen of the United States of America/Consular Report of Birth.f. FS-545 Certification of Birth issued by a U.S. Consulate or DS-1350 the Department of State Certification.g. INS N-550/570 U.S. Immigration and Naturalization Service Naturalization Certificate.h. INS N-560/561 U.S. Immigration and Naturalization Service Certificate of Citizenship. If the individual does nothave a Certificate of Citizenship, the original Certificate of Naturalization of the parent(s) may be accepted if thenaturalization occurred while the individual was under 18 years of age (or under 16 years of age before 5 October1978) and residing permanently in the U.S.i. Certificate of birth issued by the Canal Zone government indicating U.S citizenship is only acceptable if verifiedby direct government inquiry to: Vital Records Section, Passport Services, 1111 19th Street NW, Suite 510,Washington, D.C. 20522-1705.j. DD 372, Verification of Birth is acceptable for military members (officer and enlisted) provided the birth data islisted and verified by the Department of Vital Statistics.k. DD 1966, Application for Enlistment into the Armed Forces of the United States are acceptable provided thedocuments sighted are listed and attested to by a recruiting official.5. If none of the above forms of evidence are obtainable, a notice from the registrar issued by the state with theindividual’s name, date of birth, which years were searched for a birth record and that there is no birth certificate onfile for the applicant should be presented. *The registrars notice must be accompanied by the best combination ofthe following secondary evidence:a. Baptismal certificateb. Census record 14
  • Naval Medical Logistics Command AJ-01-09c. Certificate of circumcisiond. Early school recorde. Family Bible recordf. Doctor’s record of post-natal careg. Newspaper files and insurance papers* NOTE: These documents must be early public records showing the date and place of birth, created within thefirst five years of life. The individual may also submit an Affidavit of Birth, Form DSP-10A, from an older bloodrelative, i.e., a parent, aunt, uncle, sibling, who has personal knowledge of the birth. It must be notarized or havethe seal and signature of the acceptance agent. 15
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT IV CENTRAL CONTRACTOR REGISTRATION APPLICATION CONFIRMATION SHEETAs of June 1, 1998 all contractors must be registered in the Central Contractor Registration (CCR) as aprerequisite to receiving a Department of Defense (DoD) contract. You may register in the CCR through theWorld Wide Web at http://www.ccr.gov. This website contains all information necessary to register in CCR.An extract from this website is provided as Attachment 4 to this application.You will need to obtain a DUNS (Data Universal Numbering System) number prior to registering in the CCRdatabase. This DUNS number is a unique, nine-character company identification number. Even though you are anindividual, not a company, you must obtain this number. Please contact Dun & Bradstreet at 1-800-333-0505 torequest a number or request the number via internet at http://fedgov.dnb.com/webform.The CCR also requires several other codes as follows:CAGE Code: A Commercial and Government Entity (CAGE) code is a five-character vendor ID number usedextensively within the DoD. If you do not have this code, one will be assigned automatically after you complete andsubmit the CCR form.US Federal TIN: A Taxpayer ID Number or TIN is the same as your Social Security Number.NAICS Code: A North American Industry Classification System code is a numbering system that identifies the typeof products and/or services you provide. The NAICS Code for Radiologists is 622110.SOCIO-ECONOMIC FACTORSUp to 3 of the choices provided may be checked. Even though you are an individual, you are considered a businessunder this category, so check any (up to 3) that may apply. For example, any woman applying for this positionwould be considered a “Woman Owned Business;” just as any Veteran would be a “Veteran Owned Business.” Ifboth apply (or more), all would be checked.If you encounter difficulties registering in the CCR, contact the CCR Registration Assistance Centers at1-888-227-2423. Normally, registration completed via the Internet is accomplished within 48 hours. You areencouraged to apply for registration immediately upon receipt of the Notice of Contracting Opportunity.Any contractor who is not registered in CCR will NOT get paid.Complete the following and submit with initial offer: Name: _____________________________________________ Company: __________________________________________ Address: __________________________________________ __________________________________________CENTRAL CONTRACTOR REGISTRATION INFORMATION:Date CCR application was submitted: ________________________________Assigned DUN & BRADSTREET #: ________________________________Assigned CAGE Code: ________________________________ 16
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT V SMALL BUSINESS PROGRAM REPRESENTATIONSAs stated in paragraph I.A. of this application this position is set-aside for individuals. As an individual you areconsidered a Small Business for statistical purposes. If you are female, you are considered a woman-owned smallbusiness. If you belong to one of the racial or ethnic groups in section B, you are considered a small disadvantagedbusiness. To obtain further statistical information on Women-Owned and Small Disadvantaged Businesses you arerequested to provide the additional information requested below.NOTE: This information will not be used in the selection process nor will any benefit be received by an individualbased on the information provided.Check as applicable:Section A. ( ) The offeror represents for general statistical purposes that it is a woman-owned small business concern. ( ) The offeror represents, for general statistical purposes, that it is a small disadvantaged business concern as defined below. ( ) The offeror represents for general statistical purposes that it is a service disabled veteran owned small business.Section B. [Complete if offeror represented itself as disadvantaged in this provision.] The offeror shall check the category in which its ownership falls: ___ Black American ___ Hispanic American ___ Native American (American Indians, Eskimos, Aleuts, or Native Hawaiians) ___ Asian-Pacific American (persons with origins from Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Japan, China, Taiwan, Laos, Cambodia (Kampuchea), Vietnam, Korea, The Philippines, U.S. Trust Territory of the Pacific Islands (Republic of Palau), Republic of the Marshall Islands, Federated States of Micronesia, the Commonwealth of the Northern Mariana Islands, Guam, Samoa, Macao, Hong Kong, Fiji, Tonga, Kiribati, Tuvalu, or Nauru) ___ Subcontinent Asian (Asian-Indian) American (persons with origins from India, Pakistan, Bangladesh, Sri Lanka, Bhutan, the Maldives Islands, or Nepal)Offeror’s Name : ___________________ (Please print)Notice of Contracting Opportunity No. : AJ-01-09 17
  • Naval Medical Logistics Command AJ-01-09 ATTACHMENT VI HEALTH EXAMINATION AND IMMUNIZATION/SCREENING REQUIREMENT FORM AFTER contract award, but prior to performing services, the contract health care worker shall have this form completed by a licensed medical practitioner. All health care workers providing services under this contract must meet all the requirements specified under the “Required Documentation” column of this form.* COPIES OF IgG TITER LABORATORY RESULTS MUST BE ATTACHED TO THIS FORM IMMUNIZATIO DATES and RESULTS REQUIRED N/ (to be completed by examining DOCUMENTATION SCREENING licensed practitioner)VARICELLA Physician documented history of varicella Hx:(CHICKENPOX) (chickenpox/herpes zoster) disease, OR 2-dose vaccine series, OR Dates of Shots: 1. 2. Positive IgG titer Titer/Date:MEASLES/ MMR live virus 2-dose vaccine, OR Dates of Shots:MUMPS/ 1.RUBELLA 2.(MMR) Positive IgG titer for each of Measles, Mumps, and Titer/Date: Rubella HEPATITIS B HBV 3-dose vaccine series AND positive IgG titer, Dates of Dates of Repeat Shots: OR Shots: 1. HBV 3-dose vaccine series with negative titer AND 1. 2. repeat 3-dose HBV series with repeat titer AND in the 2. 3. case of persistent negative titer, counseling by licensed 3. Titer/Date: practitioner regarding implications of non-response. Titer/Date: Counseling provided: TETANUS/ Tetanus/Diphtheria (TD) booster, OR Date of TD booster: DIPHTHERIA Tetanus/Diphtheria/Pertussis (Tdap) within the Date of Tdap: preceding 10 years.TUBERCULOSIS Two-step Tuberculin Skin Test (TST), OR 2-Step TST dates: BAMT date: 1st test: One Blood Assay for Mycobacterium Tuberculosis 1st result: Result: (BAMT), OR 2nd test: Date/result of last An annual evaluation if known TST reactor, including 2nd result: annual eval: chest x-ray within 1 year if new hire CXR Date: Pos: Neg: LATEX Latex sensitivity screening questionnaire administered Date of evaluation: Results: Sensitive Not sensitive If latex sensitivity suspected, follow with appropriate Date of test: allergy testing Results: ____________________________ [Name of Contract Health Care Worker] has presented for a physical examination. He/She is applying for the position of ______________________[Please enter job title]. He/She was examined on __________________ [date] and found to be in good health, meeting the immunization/ screening required above, and is free of any medical condition or infectious disease that may prevent his/her ability to perform services for the position described above. YES NO [Please circle either YES or NO.] 18
  • Naval Medical Logistics Command AJ-01-09Provider’s Signature: _________________________ Provider’s Name: ____________________________Facility/Address: ______________________________________________________________________Phone Number: _____________________ Date: ___________________________*The facility will identify any incumbent HCWs who are not required to complete this documentation. 19