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Section B. Section B. Document Transcript

  • ET-03-09 NOTICE OF CONTRACTING OPPORTUNITY APPLICATION FOR INDIVIDUAL SET ASIDSE (ISA) CONTRACT POSITION ORAL MAXILLOFACIAL SURGEON NAVAL MEDICAL CENTER PORTSMOUTH, VA REQUIREMENTS PACKAGE- ET-03-09 9 SEPTEMBER 2009 THIS IS NOT A CIVIL SERVICE POSITIONI. IMPORTANT INFORMATION: CUTOFF DATE AND TIME FOR RECEIPT OF APPLICATIONS IS 3:00PM EST ON OR BEFORE 16 OCTOBER 2009. SEND APPLICATIONS TO THE FOLLOWING ADDRESS:NAVAL MEDICAL LOGISTICS COMMANDATTN: CODE 024T1681 NEIMAN STREETFORT DETRICK, MD 21702-9203E-MAIL: Acquisitions@med.navy.milIN SUBJECT LINE REFERENCE: “CODE 024T”A. NOTICE. This position is set-aside for individual Oral Maxillofacial Surgeons only. Applications fromcompanies will not be considered; additionally, applications from active duty Navy personnel, civilian employeesof the Navy, or persons currently performing medical services under other Navy contracts will not be consideredwithout the prior approval of the Contracting Officer. The Government anticipates award of one contract as aresult of this Notice Of Contracting Opportunity.B. POSITION SYNOPSIS: ORAL & MAXILLOFACIAL SURGEON - The Government is seeking to placeunder contract an individual who holds a current, unrestricted license to practice as a General Dentist in any oneof the fifty States, the District of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.This individual must also (1) have completed a post-doctoral program in Oral Maxillofacial surgery approved bythe ADA, (2) have a minimum of 4 years clinical post-residency experience as an Oral Maxillofacial Surgeon,(3)have been awarded board certification, (4) meet all the requirements contained herein; and (5), competitively winthis contract award (see Section II, Paragraphs D and E).Services shall be provided in support of the Naval Medical Center Portsmouth, VA, and associated branch clinics.Regular Duty Hours. You shall be on duty in the assigned clinical areas for 80 hours per two week period.Services shall normally be provided for 8 1/2 hours or 9 hours (to include ½ hour to 1 hour for an uncompensatedmeal break) each day, between the hours of 0600 and 1800, Monday through Friday, throughout the term of thecontract. You will also be required to assist with forensic dental exams required by the pathology lab to meetgovernment biopsy requirements shared on an equal basis with the military oral surgeons and general dentist. Youwill also be required to treatment plan, operate and assist with scheduled orthognathic cases, as well as, manageand treat patients requiring the full scope of Oral & Maxillofacial Surgery expertise in our clinic, in the hospitaland the Main Operating Room.On Call Hours. You shall share in the provision of on-call services. On-call services may be required at any timeduring the day or night, including weekends and holidays. On-call hours are weekdays from the end of the normalworking hours until 0630 the following morning, and on weekends and federal holidays from 0700 to 0700 thefollowing day (a 24-hour period). You shall rotate on-call services with other dentists at the facility. Typically,these services shall be assigned two to three weekdays per month and one weekend every other month, as theprovider rotation requires. Historical data indicates that on-call providers are required to be physically present inthe facility to provide services on an average of 2 hours per month. This historical data is provided forinformational purposes only and the actual number of called-in hours may vary. The schedule for on-call serviceswill be published at least 15 days prior to being assigned a duty period. The on-call services are the responsibility 1
  • ET-03-09and prerogative of the Commanding Officer or his/her designated representative. Should the HCW be required tocome into the facility in response to a page, they shall be granted a minimum of 2 hours of compensatory time off,to be scheduled at the mutual agreement of the commanding officer and the HCW. The HCW shall be providedwith a beeper to facilitate provision of these services. The HCW is responsible for replacing a lost or stolenbeeper. Provision of on call service is not separately priced.Your services shall not be required on federally established holidays unless these holidays fall on a scheduled oncall period. You shall be credited for 8 hours worked for each holiday (if work is required on a holiday, a paidcompensatory 8-hour day off will be granted).Occasional travel for training or completion of duties may be required for government approved continuingeducation. These courses will be examined by the appropriate military authority and approved on a case by casebasis. Pending approval, if travel is required, advanced notice will be provided and all reasonable travel expenseswill be reimbursed by the Government.You shall accrue 4.6 hours of leave at the end of 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 thebalance carried over is used by 31 December of that same calendar year. This contingency for leave carry overdoes not apply if the following option period is not exercised by the Government or during the last option year ofthe contract. This position is for a period beginning from the start date through 30 September of the same fiscalyear with options to extend the contract for a total of five years. The contract will be renewable each fiscal yearat the option of the Navy. You shall be compensated by the Government for these periods of planned absence.This position is for a base period beginning from the start date (a date agreed upon between the successfulapplicants and the Government), through September 30 of the same fiscal year with options to extend the contractfor 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 Medical Center Portsmouth, VA,or designated representative, e.g. Contracting Officer Representative, Technical Liaison, or Department Head.B. SUITS ARISING OUT OF MEDICAL MALPRACTICE. You will be serving at the military treatmentfacility under a personal services contract entered into under the authority of section 1091 of Title 10, UnitedStates Code. Accordingly, section 1089 of Title 10, United States Code shall apply to personal injury lawsuitsfiled against you based on or wrongful acts or omissions incident to performance within the scope of this contract.You are not required to maintain medical malpractice liability insurance. In the event of a claim or lawsuitrelating to your performance of duties under this contract, the parties shall follow the procedures established inSECNAVINST 6300.3A, 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 ofthis contract.C. DUTIES AND RESPONSIBILITIES. You shall perform the full range of Oral & Maxillofacial surgeryprocedures, within the scope of clinical privileges granted by the Commanding Officer, on site using governmentfurnished facilities, supplies and equipment and complying with the MTFs applicable Standard OperatingProcedures (SOPs) and clinical guidelines. Workload occurs as a result of either scheduled or unscheduledrequirements for care. You are responsible for a full range of diagnostic examinations, the development ofcomprehensive treatment plans when indicated, delivery of treatment within the personnel and equipmentcapabilities of the treatment facility, provision of mandated medical surveillance and preventive services, and thequality and timeliness of treatment records and reports required to document procedures performed and careprovided. You shall refer patients to staff specialists for consultation opinions and continuation of care and shallsee the patients of other government staff health care providers who have been referred for consultation andtreatment. Productivity is expected to be comparable to that of other HCWs authorized the same scope of practice.You will be responsible for one week of hospital after hours emergency call performed in conjunction with themilitary oral surgeon’s rotational call schedule, shared on an equal basis throughout the term of the contract. Youwill also be required to assist with forensic dental exams required by the pathology lab to meet government biopsy 2
  • ET-03-09requirements shared on an equal basis with the military oral surgeons and general dentist. You will also berequired to treatment plan, operate and assist with scheduled orthognathic cases, as well as, manage and treatpatients requiring the full scope of Oral & Maxillofacial Surgery expertise in our clinic, in the hospital and theMain Operating Room.1. Administrative Duties. Perform a wide range of administrative duties related to clinical practice. Theseinclude, but are not limited to, performance improvement and quality assurance functions, family advocacyactivities, attending meetings, using computer and paper systems to document and report patient care andworkload, participating in education activities, attending in-service and orientation training, maintaining HIPAAcompliance, maintaining Joint Commission compliance, safety activities, participating in emergency preparednessand other drills, and economical use of supplies and equipment.1.1. Participate in meetings to review and evaluate the care provided to patients, identify opportunities toimprove the care delivered, and recommend corrective action when problems exist. Should a meeting occuroutside of scheduled working hours, you shall be required to read and initial the minutes of the meeting.1.2. Participate in the provision of in-service training to members of the clinical and administrative staff onsubjects germane to their specialties.1.3. Demonstrate awareness and sensitivity to patient/significant others rights, as identified within theinstitution.1.4. Demonstrate awareness of legal issues in all aspects of patient care and unit function and strive to managesituations in a reduced risk manner.1.5. Demonstrate appropriate delegation of tasks and duties in the direction and coordination of health care teammembers, patient care, and clinic activities and provide training and/or direction as applicable to supportingGovernment employees (i.e., hospital corpsmen, students, etc.) assigned to you during the performance of duties.1.6. Maintain an awareness of responsibility and accountability for own professional practice.1.7. Participate in continuing education to meet own professional growth.1.8. Attend annual renewal of the following training requirements provided by the Government: familyadvocacy, disaster training, infection control, sexual harassment, bloodborne pathogens and fire/safety.1.9. Participate in the implementation of the MTF’s Family Advocacy Program as directed. Participation shallinclude, but not be limited to, appropriate medical examination, documentation and reporting.1.10. Attend Composite Healthcare System (CHCS)/Armed Forces Health Longitudinal Technology Application(AHLTA) training provided by the Government for a minimum of four (4) hours, and up to a maximum of 40hours.1.11. Adhere to infection control guidelines and practice universal precautions.1.12. Contribute to the safe and effective operation of equipment used in patient care within a safe workingenvironment. This shall include safe practices of emergency procedures, proper handling of hazardous materialsand maintaining physical security.1.13. Comply with the HIPAA (Health Insurance Portability and Accountability Act) privacy and securitypolicies of the treatment facility.1.14. Maintain statistical records of clinical workload. Operate and manipulate automated systems such asAHLTA/CHCS, participate in education programs, participating in education programs and participating inclinical staff quality assurance functions and Process Action Teams, as prescribed by the Commanding Officer.1.15. Participate in health education. 3
  • ET-03-091.16. Participate in clinical staff quality improvement/management functions to include participation in peerreview and performance improvement activities.1.17. Provide timely documentation in the form of legible, accurate records/notes of the procedures performedand the care rendered to patients in accordance with the MTF requirements and professional standards.1.18. RESERVED1.19. Possess and maintain current certification in American Heart Association Basic Life Support (BLS) forHealthcare Providers; American Heart Association Healthcare Provider course; American Red Cross CPR (CardioPulmonary Resuscitation) for the Professional Rescuer; or an equivalent MTF course. HCWs, 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 Webat: http://navymedicine.med.navy.mil/Files/Media/directives/1500-15a.pdf.1.20 Possess and maintain current certification in American Heart Association Advanced Cardiac Life Support(ACLS) and Pediatric Advanced Life Support (PALS). HCWs, not currently in possession of current certification,must acquire certification prior to initiating contract performance.2. CLINICAL RESPONSIBILITIES. Perform a full range of Oral & Maxillofacial Surgery services, usinggovernment furnished supplies, facilities and equipment within the assigned unit of the Medical TreatmentFacility (MTF). In addition to those procedures identified in Enclosure I, you shall provide the following services:2.1. Provide a full range of Oral & Maxillofacial surgery services in accordance with privileges granted by thecommander/Commanding Officer.2.2. Provide technical direction or assist in the instruction of, other health care professionals seeing patientswithin the scope of their clinical privileges or responsibilities.2.3. Request consultation or referral with appropriate dental specialists, physicians, clinics, or other healthresources as indicated.2.4. Order diagnostic tests as applicable.2.5. Prescribe and dispense medications as delineated by the Pharmacy and Therapeutics Committee.2.6 Evaluation and treatment of facial pain patients; treat patients who have behavior or communicationproblems.2.7 Evaluate and treat patients with traumatic injuries of the maxillofacial region; utilize main operating room atNaval Medical Center Portsmouth when the applicable to the situation.2.8 Evaluate and treat pre-prosthetic and dental implant patients as appropriate. Act as a member of thecommand dental implant board.2.9 Provides moderate to deep sedations and outpatient general anesthesia for selected patients in the clinicalsetting per Naval Medical Center Portsmouth, VA sedation guidelines.3. Orientation:3.1. You shall undergo a one-day on-site orientation period. Orientation shall include familiarization with thefacility, introduction to the Quality Improvement Program, introduction to MTF rules and regulations,introduction to military protocols such as military structure, time and rank, acquisition of parking permits, properinfection control protocols and clarification of rights and responsibilities.3.2. Joint Commission requirements - Comply with the standards of the Joint Commission, applicableprovisions of law and the rules and regulations of any and all governmental authorities pertaining to: 4
  • ET-03-093.1. Licensure and/or regulation of healthcare personnel in treatment facilities, and3.2. The regulations and standards of professional practice of the treatment facility, and3.3. The bylaws of the treatment facility’s professional staff.4. Credentialing Requirements:4.1. 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 degreesand licenses, 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 careservices. BUMED Instruction 6320.66E, Section 4 and Appendices B and R detail the ICF requirements.BUMEDINST 6320.66E is available at http://navymedicine.med.navy.mil/default.cfm?selTab=Directives. ClickBUMED Directives, select page 4 of the directives, and scroll down to the instruction number. The instruction isnow contained in several separate files.4.2. 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 animmediate close. Since granting credentialing/privileging is required as a condition of your employment underthe contract resulting from this Notice, then the contract will provide that a negative current clinical assessmentwill result in the issuance of a contract termination notice by the contracting officer under the clause at FAR52.249-12.4.3. 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,performance under this contract may be suspended until clinical privileges are reinstated. No reimbursement shallbe made and no other compensation shall accrue to you so long as performance is suspended or clinical privilegesare held in abeyance. The denial, suspension, limitation, or revocation of clinical privileges based uponpractitioner impairment or misconduct will be reported to the appropriate licensing authorities of the state inwhich the license is held IAW BUMEDINST 6320.66E (or latest version) and BUMEDINST 6320.67A CH01.5. 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 abilityto access and/or impact sensitive data and information. Additionally you may have contact with patients underthe age of 18. Therefore, you shall be subject to Information Technology (IT)/Sensitive Information (SI) securityrequirements which include national and local background checks and a credit check in accordance with Secretaryof Navy (SECNAV) Manual 5510.30, as well as a criminal background check in accordance with the CrimeControl Act of 1990. It should be noted that in order to receive access to the DON IT system(s) and the sensitivedata necessary to perform the duties for this position, you must be a U.S. citizen. You shall be required tocomplete the paperwork necessary for the Government to complete the background investigations.D. MINIMUM PERSONNEL QUALIFICATIONS. To be qualified for this position you must:1. Posses a doctorate in dentistry from an accredited dental school approved by the Council on Dental Educationof the American Dental Association (ADA).2. Have a current, active, unrestricted license to practice as a General Dentist in any one of the 50 States, theDistrict of Columbia, the Commonwealth of Puerto Rico, Guam or the U.S. Virgin Islands.3. Have completed a post-doctoral program in Oral Maxillofacial surgery approved by the ADA.4. Have a minimum of 4 years clinical post-residency experience as an oral maxillofacial surgeon, at least 6months of which must have occurred within the preceding 24 months of receipt of the credentials package.Possess board certification status from the American Board of Oral and Maxillofacial Surgery.5. Provide letters of recommendation from two practicing dentists and/or professors attesting to your clinical 5
  • ET-03-09skills, patient rapport, etc. Recommendation letters must include name, title, phone number, date of reference,address and signature of individual providing the letter. Reference letters must have been written within thepreceding three years.6. Possess U.S. citizenship which is necessary to gain access to DON IT systems and sensitive information (seeSection C.5). Documentation, as detailed in Attachment III shall be required after award.7. Possess American Heart Association Basic Life Support (1) for Healthcare Providers; American HeartAssociation Healthcare Provider Course; American Red Cross CPR (Cardio Pulmonary Resuscitation) for theProfessional Rescuer; or equivalent. (2) American Heart Association Advanced Cardiac Life Support andPediatric Advanced Life Support. In the event the health care worker does not possess this certification and thefacility elects to provide it, the Government reserves the right to deduct 4 hours of compensated service for eachcertification course. The Government may provide recertification.8. If awarded a contract, you will be required to obtain a physical examination and immunizations at your ownexpense prior to initiation of contract performance. The physician must complete the immunization and healthexamination form provided as Attachment VI.9. Represent an acceptable malpractice risk to the Navy.10. Be in good standing and under no sanction or suspension listing by the Federal Government.11. Submit a fair and reasonable price that has been accepted by the Government.E. FACTORS TO BE USED IN A CONTRACT AWARD DECISION. If you meet the minimum qualificationslisted in paragraph D. above entitled, "Minimum Personnel Qualifications", you shall be ranked against all otherqualified candidates. The "Personal Qualification Sheet", Letters of Recommendation, and, if you have priormilitary service, the Form DD214, shall be used to evaluate these items. Following are the ranking criteria listedin descending order or importance:1. Quality and quantity of training and experience as it relates to the duties contained herein. The letters ofrecommendation required under Item D.5, above, shall be assessed when evaluating this factor. Those letters mayenhance your ranking if they substantively address items such as clinical skills, professionalism, or specific areasof expertise, 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, then,2. Prior relevant experience in a military Dental/Medical facility (provide Form DD214 if prior active duty).F. INSTRUCTIONS FOR COMPLETING THE APPLICATION. To be qualified for this contract position, youmust submit the following:1. _____ A completed* "Personal Qualifications Sheet – Oral Maxillofacial Surgeon" (Attachment 1).2. _____ A completed Pricing Sheet (Attachment 2).3. _____ Proof of citizenship requirements (Attachment III) Please submit copies with your application. If youare awarded 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. _____ Two letters of recommendations per paragraph D.5. above.7. _____ Physical certification requirements (only if awarded with contract) per paragraph D.8. above.*Please answer every question on the "Personal Qualifications Sheet – Oral Maxillofacial Surgeon" Mark "N/A" ifthe item is not applicable.G. OTHER INFORMATION FOR OFFERORS.The ISA HANDBOOK is available at http://www.nmlc.med.navy.mil/index.asp . Click “Doing Business With 6
  • ET-03-09Us” and select Individual Set-Asides, OR can be requested from the contract 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 qualifiedindividual, or (4) Make contract award from your application. If you are the successful applicant, the contractingofficer will mail to you a formal government contract for your signature. This contract will record the negotiatedprice, your promise to perform the work described above, how you will be paid, how and by whom you will besupervised, and other rights and obligations of you and the Navy. Since this will be a legally binding document,you should review it 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 II, Pricing Information. Beforecommencing work under a Government contract, you must notify the Contracting Officer in writing that therequired insurance has been obtained.A complete, sample contract is available upon request.Questions concerning this package may be addressed at (301) 619-8277We look forward to receiving your application. 7
  • ET-03-09 ENCLOSURE I ORAL MAXILLOFACIAL SURGERY– BASIC PROCEDURESGeneral dentistry core privileges and:- Comprehensive oral maxillofacial surgery examination, consultation, and treatment planning- Dentoalveolar surgery; extraction of soft and hard tissue impaction, intentional tooth replantation or transplantation, root-end resection and root-end filling, sequestrectomy, stomatoplasty, ridge augmentation, alveoloplasty, osseo-integrated implants, and oral antral/oral nasal fistula repair- Management of cervical-facial infections- Comprehensive management of oral manifestations of chronic systemic diseases, e.g., lichen planus,pemphigoid and erythema multiforme- Repair traumatic wounds: oral and facial- Repair and management of facial fractures: alveolar, maxilla, mandible, nasoethmoidal, zygoma, frontal- Tracheostomy- Nasal antrostomy- Maxillary sinusotomy- Therapeutic medication by injection- Craniofacial analysis- Extracranial facial osteotomies- Augmentation, contouring, reductions of hard and soft tissue- Marsupialization- Soft tissue grafts- Vestibuloplasty, frenectomy, mucogingival surgery- GTR- Minimal Sedation/Anxiolysis inhalation sedation with nitrous oxide/oxygen- Minimal sedation/axiolysis.- Moderate Sedation/analgesia- General anesthesia- Nonsurgical management of temporomandibular joint disorders- History and physical examination, hospital admission: adult and pediatric- Resection of maxilla, mandible- Major salivary gland surgery- Sialography- Minor tooth movement- Placement maxillofacial devices- Arthrogram- Arthroscopy- Temporomandibular joint surgery- Preprosthetic reconstructive surgery- Scar revision: oral and facial- Reconstruction of the facial skeleton- Excision of benign and malignant tumors and cysts of the hard and soft tissues- Harvest of hard and soft tissue grafts- Alveolar cleft repairORAL AND MAXILLOFACIAL SURGERY – Advanced Procedures, as authorized by the CommandingOfficer- Cleft lip repair- Cleft palate repair- Craniofacial implants- Liposuction- Microneural repair- Microvascular reconstruction- Laser surgery- Cranial bone graft- Rhinoplasty 8
  • ET-03-09- Blepharoplasty- Rhytidectomy- Otoplasty- Chemical peel- Dermabrasion- Hair Transplant 9
  • ET-03-09 ATTACHMENT I PERSONAL QUALIFICATIONS SHEET (PQS) – ORAL & MAXILLOFACIAL SURGEON1. Every item on the Personal Qualifications Sheet must be addressed. Please sign and date where indicated.Any additional information required may be provided on a separate sheet of paper (indicate by number andsection the question(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 recommendationand two letters of clinical competency as described in Section D.5 and Item IV of this 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,all medical 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 forwardedto your 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.5. Personal and Practice Information: 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 number3 above. If you hold a dual citizenship or have a passport issued from a foreign country, address which countrythe dual citizenship is held and/or which foreign country has issued you a passport.A. General InformationName: SSN:_______________________Last First Middle 10
  • ET-03-09Date of Birth: ____________________Address: ___________________________________ ___________________________________ ___________________________________Phone: ( ) ________________B. Medical Information YES NO1. Do you have any physical handicap or condition 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? ___ ___4. Do you currently have, or in the past have you everhad, an alcohol dependency? ___ ___5. Are you currently receiving, or have you in the pastever received, therapy for any alcohol related problem? ___ ___6. Have you ever been unlawfully involved in the use ofcontrolled substances? ___ ___7. Are you currently receiving, or have you in the pastever received, therapy for any drug-related condition? ___ ___C. Health Certification. Individuals providing services under Government contracts are required to undergo aphysical exam within 60 days prior to beginning work. The exam is not required prior to award but is requiredprior to the performance of services under contract. You must acknowledge this requirement by signing below._______________________________ _________ (Signature) (Date) 11
  • ET-03-09I. PROFESSIONAL INFORMATIONA. Advanced Education.1. Medical School:a. Name of Accredited School Date of Training (From) (To)_________________________________ ______ ______b. Type of Degree:_____________________________________c. Location and Address of School:__________________________________________________________________________________________________________________________________________d. Name of Accredited School: Date of Training (From) (To)_________________________________ ______ ______e. Type of Degree:_____________________________________f. Location and Address of School:__________________________________________________________________________________________________________________________________________2. Additional Education:a. Name of Accredited School: Date of Training (From) (To)_________________________________ ______ ______b. Type of Degree:_______________________________c. Location and Address of School:__________________________________________________________________________________________________________________________________________d. Name of Accredited School: Date of Training (From) (To)_________________________________ ______ ______e. Type of Degree:_______________________________f. Location and Address of School:__________________________________________________________________________________________________________________________________________3. Continuing Education:Title of Course From To CE Hours________________________________________________________________ 12
  • ET-03-09________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________4. Certifications YES NOBLS Level C ____ ____Expiration Date: _________NRP ____ ____Expiration Date: _________ACLS ____ ____Expiration Date: _________ATLS ____ ____Expiration Date: _________PALS ____ ____Expiration Date: _________B. Professional Employment. List your current and preceding employers for the past 5 years:1. Name and Address of Present Employer(s): From: ___________ To: ____________a. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ b. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________2. Name and Address of Preceding Employers for the last 5 years:a. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ 13
  • ET-03-09 Position/Title: ____________________________ From: _______________ To: __________________ Name and Address of Preceding Employers for the last 5 years (continued): b. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: ____________________________ From: ______________ To: ___________________ c. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: ____________________________ From: ______________ To: ___________________ d. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: ____________________________ From: ______________ To: ___________________ e. _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: _____________ To: __________________ f. ____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: _____________ To:___________________ g. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: _____________ To: ___________________3. List military experience providing medical services: a. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: ______________ To: __________________ b. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: _______________ To: _________________ c. _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Position/Title: _____________________________ From: _______________ To:_________________4. Provide an explanation of any gaps in employment within the time specified in B above on a separate sheet ofpaper.5. Are you currently employed on a Navy contract? If yes, where is your current contract and what is theposition? 14
  • ET-03-09_____________________________________________6. RESERVED7. Experience in clinical type computer systems: Identify any computer systems withwhich you are familiar (i.e. CHCS/AHLTA).____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C. RESERVEDD. Licensure (to include all medical licenses held)1. License Number State Date of Expiration_____________ ____ ___________________________ ____ ___________________________ ____ ___________________________ ____ ___________________________ ____ ______________II. Enhancing FactorsThose items that may enhance the ranking of a candidate, as described in the cover memorandum, shall beattached to this application. This includes letters of recommendation and other such documentation.III. 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, CME certificates, commendations ordocumentation of any awards you may have received, prior military experience, etc.IV. Provide letters of recommendation from two practicing dentists and/or professors attesting to your clinicalskills, patient rapport, etc. Recommendation letters must include name, title, phone number, date of reference,address and signature of individual providing the letter. Reference letters must have been written within thepreceding three years.V. I hereby certify the above information to be true and accurate:PRIVACY ACT STATEMENTUnder 5 U.S.C. 552a and Executive Order 9397, the above information is requested for use in the consideration ofa contract. Disclosure of the information is voluntary; failure to provide information may result in the denial ofthe opportunity to enter into a contract. _______________________ _______ (mm/dd/yy) (Signature) (Date) 15
  • ET-03-09 ATTACHMENT II PRICING SHEETPERIOD OF PERFORMANCEServices are required from 12 January 2010 through 30 September 2010. The Contracting Officer reserves theright to adjust the start and end dates of performance to meet the actual contract start date. Services may also beextended by 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 considerinflation rates when pricing the option period. The Government will award a contract that is neither too high nortoo low. Your price would be high enough to retain your services but not so high as to be out of line whencompared to the salaries of other Oral & Maxillofacial Surgeons in the Portsmouth, VA area. Please note that ifyou are awarded a Government contract position, you will be responsible for paying all federal, state and, localtaxes. The Navy does not withhold any taxes. Your proposed prices should include the amount you will pay intaxes. (b) Liability Insurance: Before commencing work under a contract, you shall obtain the following requiredlevels of insurance at your own expense: (a) General Liability - Bodily injury liability insurance coverage writtenon the comprehensive form of policy of at least $500,000 per occurrence, and (b) Automobile Liability - Autoliability insurance written on the comprehensive form of policy. Provide coverage of at least $200,000 per personand $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 totalamount of compensation paid to an individual direct health care provider in any year cannot exceed the full timeequivalent annual 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 a full time Oral Maxillofacial Surgeon at the Naval Medical Center Portsmouth, VA and area medical/dental clinics in accordance with this Application and the resulting contract.0001 Base Period: 12 Jan 10 through 30 Sep 10 1,504 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 2,080 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 $______ $ _________5001 Option Period V: 01 Oct 14 through 11 Jan 15 536 HRS $______ $ _________Printed Name ___________________________________________Signature ___________________________________________ Date ________________ ATTACHMENT III PROOF OF CITIZENSHIP REQUIREMENTS 16
  • ET-03-09Excerpt 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 proof of 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 recordssuch as 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 doesnot have a Certificate of Citizenship, the original Certificate of Naturalization of the parent(s) may be accepted ifthe naturalization occurred while the individual was under 18 years of age (or under 16 years of age before 5October 1978) and residing permanently in the U.S.i. Certificate of birth issued by the Canal Zone government indicating U.S citizenship is only acceptable ifverified by direct government inquiry to: Vital Records Section, Passport Services, 1111 19th Street NW, Suite510, 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 certificateon file for the applicant should be presented. *The registrars notice must be accompanied by the bestcombination of the following secondary evidence:a. Baptismal certificateb. Census recordc. Certificate of circumcisiond. Early school recorde. Family Bible record 17
  • ET-03-09f. 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 olderblood relative, i.e., a parent, aunt, uncle, sibling, who has personal knowledge of the birth. It must be notarizedor have the seal and signature of the acceptance agent. 18
  • ET-03-09 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 throughthe World Wide Web at http://www.ccr.gov. This website contains all information necessary to register inCCR. 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 arean individual, not a company, you must obtain this number. Please contact Dun & Bradstreet at 1-800-333-0505to request 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 completeand submit 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 thetype of products and/or services you provide. The NAICS Code for an Oral and Maxillofacial Surgeon is 621210.SOCIO-ECONOMIC FACTORSUp to 3 of the choices provided may be checked. Even though you are an individual, you are considered abusiness under this category, so check any (up to 3) that may apply. For example, any woman applying for thisposition would be considered a “Woman Owned Business;” just as any Veteran would be a “Veteran OwnedBusiness.” If both apply (or more), all would be checked. If you encounter difficulties registering in the CCR, contact the CCR Registration Assistance Centers at 1-888-227-2423. Normally, registration completed via the Internet is accomplished within 48 hours. You are encouraged 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: ________________________________ 19
  • ET-03-09 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 smalldisadvantaged business. To obtain further statistical information on Women-Owned and Small DisadvantagedBusinesses you are requested 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. : ET-03-09 ATTACHMENT VI HEALTH EXAMINATION AND IMMUNIZATION/SCREENING REQUIREMENT FORM 20
  • ET-03-09 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: RubellaHEPATITIS 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 3. Titer/Date: licensed practitioner regarding implications of non- Titer/Date: Counseling provided: response.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 BAMT date: dates: One Blood Assay for Mycobacterium Tuberculosis 1st test: Result: (BAMT), OR 1st result: Date/result of last An annual evaluation if known TST reactor, including 2nd test: annual eval: chest x-ray within 1 year if new hire 2nd result: 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.] Provider’s Signature: _________________________ Provider’s Name: ____________________________ Facility/Address: ______________________________________________________________________ 21
  • ET-03-09Phone Number: _____________________ Date: ___________________________*The facility will identify any incumbent HCWs who are not required to complete this documentation. 22