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Peace Corps Dental Consultation Services RFP

Peace Corps Dental Consultation Services RFP

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Peace Corps Dental Consultation Services Request for Proposals.
Peace Corps Dental Consultation Services Request for Proposals.

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Published by: Accessible Journal Media Peace Corps Docs on May 30, 2011
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SOLICITATIONfCONTRACTfORDER

OFFEROR 2. CONTRACT NO TO COMPI.ETE

BLOCKS

7.

FOR SOUCITA TlON II'4FORMA TlON CALL:

~

I~

I

FOR COMMERCIAL ITEM
12, 17, 23, 24, & 30
ORDER NUMBER

3. AWAADI EFFECTIVE DATE

r

11. REQUISITION NUMBER

Angela

NAME

Bailey
CODE

I~
D NAICS:

I

OF IPAG~

I 61

PC-11-P-AB07
(No ooIIoct CIlOs)

SOLiGITATION NUMBER

TELEFHONE NUMBER

202-692-1713 IZI SET ASIDE:

I~'

I~'

SOLICITATION SSUE DATE

OS/24/2011 1200 ET

OFFER DUE DATEILOCAL TIME

06/07/2011

9. ISSUED BY

IpCISSUE

1D.THIS Ac:OUISITION IS UNRESTRICTED OR

Peace Corps 1111 20th Street, NW Acquisitions & Contract 4th flr Washington DC 20526
11. DELIVERY FOR FOB DEsnNA TION UNLESS BLOCK IS MARKED

100. 00% FOR:
DEMERGING SMALL BUSINESS DSOLE SOURCE

IXI SMALL BUSINESS

Management

621210

o HUezONE

SMALL BUS1NESS

SIZE STANDAAD:

$7.0
tu. ClISCQUNT TERMS 013 •. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR 700)

o SERVICE· DISABLED VETERANDIIINED SMALL BUSINESS 13b.RATING 14. METHOD OF SOLICITATION ORFQ OlFB CODE

06(A)

o SEE SCHEDULE

g! RFP

15 DELIVER TO

CODE

I

16. ADMINISTERED BY

IPCOACM

Peace C;:orps 1111 20th Street, NW Acquisitions & Contract 4th Flr Washington DC 20526
170. CONTRACTOR! OFFEROR CODe

Management

I

FACILITY CODE

I

18a PAVMENT WILL BE MADE BY

CODE

I

TELEPHONE NO. D17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 19. ITEM NO 20. SCHEDULE OF SUPPLIES/SERVICES lab. SUBMIT INVOICES TO ADDRESS SHOIIIN IN BLOCK 16. UNLESS BLOCK BELOW IS CHECKED OSEE ADDENDUM 22 UNIT 23. UNIT PRICE 24. AMOUNT 21. QUANTITY

Tax ID Number: Not Available DUNS Number: Not Available This solicitation depicts the schedule with a 12 month period of performance .from 08/1/2011 through 07/31/2012. The contractor shall provide firm fixed prices for the term of the contract in the requirement for servic ~s to he Peace and administration of dental consultation services as pe S ction for Proposal.
(Use Reverse and/or Attach Additional Sheets as Necessary)
25, ACCOUNTING ANO APPROPRIATION OATA

n support Corps C of t~e Request

r'

TOTAL AWARD

AMOUNT

(For Govt. Use Only)

lZi27a. 027b 028.

SOLICITATION

INCORPORATES ORDER

BY REFERENCE INCORPORATES

FAR 52.212·1,

52.212-4.

FAR 52,212-3

AND 52.212·5

ARE ATTACHED,

ADDENOA

DARE

CONTRACT/PURCHASE CONTRACTOR

BY REFERENCE

FAR 52,212-<1. FAR 52.212·5

IS ATTACHED.

AOOENDA OF CONTRACT REF. . YOUR OFFER ANY ADDITIONS OR CHANGES

o ARE
WHICH

IZI ARE
DARE

NOT ATTACHED NOT ATTACHED OFFER

IS REQUIRED OFFICE

TO SIGN THIS DOCUMENT CONTRACTOR AGREES IDENTIFIED ABOVE

ANO RETURN AND DELIVER AND ON ANY ADDITIONAL HEREIN.

o

29. AWARD DATED INCLUDING HEREIN,

COPIES SHEETS

TO ISSUING SUBJECT

TO FURNISH SPECIFIED

ON SOLICITATION

(BLOCK

5),

ALL ITEMS SET FORTH

OR OTHERWISE

ARE SET FORTH

TO THE TERMS AND CONDITIONS

IS AC

S TO ITEMS:

3Da. SIGNATURE OF OFFERoRICONTRACTOR

30b. NAME AND TITLE OF SIGNER

(Type or prtnt)

30c

DATE SIGNED

AUTHORIZED PREVIOUS

FOR LOCAL REPRODUCTION EDITION IS NOT USABLE

2 of
19. ITEM NO. 20. SCHEDULE OF SUPPLlESlSERVlCES 21. 22. QUANTITY UNIT 23 UNtTPRICE

61
24. AMOUNT

The provisions effect

and clauses

incorporated

into this ~olici in

at on document ncorporated text. ul

~re those

in

at the time of solicitation. acquisition regulation Offeror

Provisions

and claus~s

'.)y reference at he

have the same force and effect the federal provision http://www.arnet.gov/far. at 52.212-3, offer Items, with Solicitation writing,

as if they were given must subm·t

The fJll text of

(FAR) can be ac essed on the internet a c)mp ete copy of ic tions and Certi

The Contractor 35 of RFP). be accepted Eastern

Representations

- Commercial

(see page

submittals

shall

in to Anpela Time ion B il y, Contract (ES ) on June ~pecia1ist, Standard 7, 2011. ~t pe

via UPS,

Federal

Express

or Courier

abailey@peacecorps.gov All questions registered contract. Period of Performance: must

by 12:00pm

be sent in writing by 12:00pm Contractor

to the atten

0

A gela Bailey must prior

abailey@peacecorps.gov at Central

est on May 31, 2011. Registration to 07/31/2012

C)nt actors

(www.ccr.g)v)

to awa d of any

08/01/2011

328. QUANTITY

IN COLUMN

21 HAS BEEN

o

RECEIVED

o

INSPECTED GOVERNMENT

o
GOVERNMENT

ACCEPTED, NOTED·

AND CONFORMS

TO THE CONTRACT,

EXCEPT AS

32b. SIGNATURE

OF AUTHORIZED

REPRESENTATIVE

13le.

DATE

320. PRINTED

NAME AND TITLE OF AUTHORIZED

GOVERNMENT

REPRESENTATIVE

328. MAILING

ADDRESS

OF AUTHORIZED

REPRESENTATIVE

32f. TELEPHONE

NUMBER

OF AUTHORIZED

GOVERNMENT

REPRESENTATIVE

329. E-MAIL OF AUTHORIZED

GOVERNMENT

REPRESENTATIVE

33. SHIP NUMBER

34 VOUCHER

NUMBER

35. AMOUNT CORRECT

VERIFIED

36. PAYMENT

37. CHECK

NUMBER

FOR

o

PARTIAL

D

D
FINAL 39 SIR VOUCHER NUMBER 40. PAID BY

COMPLETE

D

PARTIAL

D

FINAL

38. SIR ACCOUNT

NUMBER

418. I CERTIFY 410. SIGNATURE

THIS ACCOUNT

IS CORRECT

AND PROPER OFFICER

FOR PAYMENT 41c. DATE

428

RECEIVED

BY (Print)

AND T!TLE OF CERTIFYING

42b. REC EIVED AT (Location)

42C. DATE REC'O (YVJMMIDD)

142d

TOTAL

CONTAINERS

STANDARD

FORM

144'

(REY,3IZ0061

BACK

PC-11-P-AB07

SECTION B- SUPPLIES/SERVICESAND PRICES B.1 Purpose services as detailed in Section C.l General

The Peace Corps requires dental consultation Background. B.2 Contract Type

This is a Firm-Fixed Price Contract. For consideration set forth in the contract the contractor shall provide all personnel, services, supplies, materials in order to perform the tasks detailed

by the Statement of Work in Section C.
B.3 Schedule of Prices in CLiNS 001A-00Se.

Note: The unit price is all-inclusive as identified Base Year - 08/01/201107/31/2012

CLiN/Description of Supply/Service 001A Field Consultation 001B Post Service Evaluations 001C All Other Consultations Option Year 1- 08/01/2012

Qty

Unit

Unit Price

Extend Price

SOO SOO
100

EA
EA

$ $

$

HR

s
Unit Price

$

$

- 07/31/2013

CLiN/Description of Supply/Service 002A Field Consultation . 002B Post Service Evaluations 002C All Other Consultations Option Year 2 - 08/01/2013

Qty

Unit EA EA

Extend Price

SOO
500 100

HR

$ $ $

$ $

s

- 07/31/2014

Cli N/Description of Supply/Service 003A Field Consultation 003B Post Service Evaluations 003C All Other Consultations

Qty
500 500 100

Unit EA EA

Unit Price

Extend Price

$
$

s

HR

$

$ $

3

PC-11-P-AB07

Option Year 3 - 08/01/2014

- 07/31/2015 Qty 500 500 100 Unit EA EA HR Unit Price Extend Price

CLiN/Description of Supply/Service 004A Field Consultation 0048 Post Service Evaluations 004C All Other Consultations Option Year 4 - 08/01/2015

$ $ $

$ $ $

- 07/31/2016 Qty SOO 500 100 Unit EA EA Unit Price Extend Price

CLiN/Description of Supply/Service 005A Field Consultation 0058 Post Service Evaluations OOSCAll Other Consultations

HR

$ $ $

$ $

$

END OF SECTION B

SECTION C- STATEMENT OF WORK [SPECIFICATIONS C.1 GENERAL BACKGROUND Peace Corps is an independent executive agency of the Federal Government established in 1961 by President John F. Kennedy to promote world peace and friendship through the service of American volunteers abroad. The volunteers' service fulfills the three primary Peace Corps goals established in the founding legislation: 1) Helping the people of interested countries in meeting their need for trained men and women. 2) Helping promote a better understanding of Americans on the part of the peoples served 3) Helping promote a better understanding of other peoples on the part of Americans. The agency currently manages more than 8,655 volunteers in approximately 77 international posts. The Volunteer Health System is administered by the Office of Medical Services (OMS) under the supervision of the Associate Director for Volunteer Support. OMS is responsible for: 1) providing case consultation and case management assistance and support through in-country Peace Corps Medical Officers (PCMOs) and OMS Washington staff; 2) evaluating servicerelated health conditions for six months after completion of service; and, 3) liaison between

4

PC-11-P-AB07

former Volunteers and the Department fited by former Volunteers.

of Labor Office of Workers' Compensation

for claims

C.2 SCOPE The Peace Corps has a requirement for dental consultation services for the assessment of dental conditions and administration of Peace Corps dental policies.(See Attachment 1 in Section J for Peace Corps Dental Technical Guidelines). The workload is estimated by number of field consultations performed of reviews per month may fluctuate. and post-service evaluations The number

historically and the estimated amount of potential new volunteers.

C.3 MANDATORY REQUIREMENTS The Contractor shall:

Review requests for consultation from PCMOs ("field consultations") and recommend management of the dental condition at overseas posts with locally available resources or at a dental service location outside of the country of service; Review the dental records of selected former Volunteers ("post-service evaluations") for purposes of determining coverage under the Peace Corps Act and the Federal Employees' Compensation Act (FECA); Formally recommend changes in process or procedure as requested; Provide consulting services to staff regarding cases, policy and training; Record dental cases in Peace Corps computer systems; Submit monthly and annual reports. Provide back-up coverage if unable to provide services for more than two business days.

• • • • •

Adhere to Peace Corps standards for medical confidentiality Privacy Act.

including HIPPA and the

The contracting dentist, professional partnership, or firm shall not be eligible to perform dental care for active duty or former Volunteers for dental conditions

5

PC-11-P-AB07

about which the Contractor contract. •

provided advice while working under the terms of this

Incur all costs for the retrieval from Peace Corps and return to Peace Corps all records and materials necessary for review.

3.1 Field Consultations
Peace Corps Medical Officers (PCMOs) at overseas posts seek advice from OMS through the field consultation process. By fax or other electronic means, the PCMO will describe a Volunteer's dental condition and any recommendations from an examining dentist, if locally available. The Contractor shall pick-up consultation requests from OMS every other day, and/or receive consultation requests by fax or electronically if possible, and create a case in the Peace Corps Volunteer Field Support Database System. The Contractor shall open, document, record his/her recommendation, and close each field consultation in the computer system provided by the Peace Corps. The Contractor shall provide a written evaluation and recommendation in the case management system within two business days of receipt. The Contractor shall also be accessible by phone for consultation with OMS staff about emergency cases. Consultations are expected to be approximately 500 per year.

3.2 Post-Service Evaluation Former Peace Corps Volunteers are covered under the Federal Employees' Compensation Act (FECA) for service-related conditions. The Contractor shall review information provided by OMS and determine whether the recommended treatment for a former Volunteer is Peace Corps service-related and, therefore, eligible for compensation. The Contractor shall pick-up consultation requests from OMS every other day, and/or receive consultation requests by fax or electronically if possible, and create a case in the Peace Corps Volunteer Post-Service Database System. The Contractor shall open, document, record recommendation, and close each post-service evaluation in the computer system provided by the Peace Corps. The Contractor shall provide a written evaluation and recommendation in the case management system within two business days of receipt. The Contractor shall also be available by phone for consultation with OMS staff about such cases within two business days of request. OMS will provide the pre-entrance dental records and x-rays, any significant information from the medical record during service, and the close of service dental examination report and x- rays. All cases with an estimated treatment cost greater than $1,000 and selected cases [i.e. such as but not limited to requests for bonding and whitening) with an estimated cost less than $1,000 shall be reviewed by the Contractor. The number of reviews per year is estimated to be approximately 500. Cases for review are to be picked up every other day

6

PC-11-P-AB07

from OMS or to be received electronically or by fax if possible, with the review completed and returned to OMS within two business days of receipt. (See Attachment 2 in Section J for a copy of the Peace Corps Dental Examination Form.) 3.3 Consultation Intermittently, OMS requires consultation on dental policy and training assistance. The contractor must be available to provide occasional consultation with managers and staff due to familiarity with Peace Corps policy and procedures regarding dental care and services. This consultation may involve advice regarding potential changes in policy (such as possible changes to Technical Guidelines Attachment 1) and/or informational meetings with overseas medical officers receiving training and orientation at PC headquarters. Consultation will occur in OMS offices ;n Washington, D.C. Consultations may also be arranged with pre-service staff. The Contractor is required to be available for meetings with Peace Corps personnel in Peace Corps headquarters as needed for review of specific cases.

4. REQUIRED REPORTS 4.1 The contractor shall prepare and submit a written monthly report to the Contracting Officers Technical Representative (COTR) by the 15th calendar day of the following month. (See Attachment 3 in Section J for monthly report format.) The report shall include:

Number of field consultations conducted, full name, age, country of service of the Volunteer, affiliated PCMO's name, Volunteer ID number, dental condition involved (by ADA code), an assessment of whether the condition could have been anticipated or prevented through screening, and comments as necessary; Number of post-service evaluations conducted, full name, age, country of service of the Returned Volunteer, affiliated PCMO's name, Volunteer ID number, dental condition involved (by ADA code), an assessment of whether the condition could have been anticipated or prevented through screening and/or care during Peace Corps service, a yes/no recorded outcome of benefits eligibility determination, identification of program as Peace Corps Volunteer (PCV) or Peace Corps Response Volunteer (PCRV) and comments as necessary; Any recommended changes in processes or procedures and any problems encountered during the reporting period; The number of hours of telephone consultations, and formal meetings with staff to address dental policy and training, along with an explanation of the services provided.

7

PC-11-P-AB07

4.2 Thirty (30) days after the end of each contract year, the Contractor shall submit a written summary report to the COTR that contains totals for all the items required on the monthly reports. The Contractor shall report its assessment and recommendation for changes in dental policy and practice.

All reports shall be provided electronically.
END OF SECTION C

SECTION 0 - PACKAGING AND MARKING

0.1

Packaging

Preservation, packaging, and packing for shipment or mailing of all work delivered hereunder shall be in accordance with sound commercial practice and adequate to ensure acceptance by common carrier and safe transportation to the destinations at the most economical rate/so

0.2

Marking

Each deliverable shall be accompanied by a letter or other document that identifies the item by Contract number and/or name of the publication under which the item is being delivered.

END OF SECTION 0

SECTION E -INSPECTION

AND ACCEPTANCE

In accordance with FAR clause 52.212-4(a), The Contractor shall only tender for acceptance those items that conform to the requirements of this contract. The Government reserves the right to inspect or test any supplies or services that have been tendered for acceptance. The Government may require repair or replacement of nonconforming supplies or reperformance of nonconforming services at no increase in contract price. If repair/replacement or re-performance will not correct the defects or is not possible, the government may seek an equitable price reduction or adequate consideration for acceptance of nonconforming supplies or services. The Government must exercise its post-acceptance rights --

8

PC-11-P-AB07

(l) Within a reasonable time after the defect was discovered or should have been discovered;
and (2) Before any substantial change occurs in the condition of the item, unless the change is due to the defect in the item. The Delivery Terms for this contract is in accordance 52.247-34 - F.o.b. - Destination (NOV 1991) a) The term "f.o.b. destination," (1) Free of expense to the Government,

with:

as used in this clause, meanson board the carrier's conveyance, at a

specified delivery point where the consignee's facility (plant, warehouse, store, lot, or other location to which shipment can be made) is located; and (2) Supplies shall be delivered to the destination the expense of the Contractor. The Government placement" consignee's wharf lif destination is a port city and supplies are for export}, warehouse unloading platform, or receiving dock, at shall not be liable for any delivery, storage, unless such capacity. If demurrage, accessorial, or other charges involved before the actual delivery (or "constructive as defined in carrier tariffs) of the supplies to the destination, charges are caused by an act or order of the Government consignee. If motor carrier (including "piggyback") the requirements acting in its contractual

rail carrier is used, supplies shall be delivered to the specified unloading platform of the is used, supplies shall be delivered to truck tailgate at the unloading platform of the consignee, except when the supplies delivered meet of Item 568 of the National Motor Freight Classification for "heavy or bulky of the referenced Item 568 are delivered, by the consignee, with uses rail carrier or freight freight." When supplies meeting the requirements

unloading (including movement to the tailgate) shall be performed assistance from the truck driver, if requested. If the contractor forwarded

for less than carload shipments, the contractor shall ensure that the carrier will

furnish tailgate delivery. when required, if transfer to truck is required to complete delivery to consignee. (b) The Contractor shall(1)(i) Pack and mark the shipment to comply with contract specifications; (ii) In the absence of specifications, carrier requirements; (2) Prepare and distribute commercial bills of lading; or with prepare the shipment in conformance

9

PC-11-P-AB07

(3) Deliver the shipment in good order and condition to the point of delivery specified in the contract;

(4) Be responsible for any loss of and/or damage to the goods occurring before receipt
of the shipment by the consignee at the delivery point specified in the contract; (5) Furnish a delivery schedule and designate the mode of delivering carrier; and (6) Pay and bear all charges to the specified point of delivery.

END OF SECTION E

SECTION F - DELIVERIES OR PERFORMANCE

F.l

Period of Performance

The estimated period of performance for this contract is one (1) base year and four (4) oneyear options. The Peace Corps shall have the unilateral right to exercise the option(s) to extend the Contract for up to four additional one-year periods, for a total performance period not to exceed five (5) years.

F.2.

Place of Performance

Office of Medical Services/Stn Floor 111120th St. NW. Washington, DC. 20526

Peace Corps

F.3

Deliverables

All deliverables and reports are the property of the Peace Corps and shall be marked, "For Official Use Only" by the Contractor.

Deliverables and reports shall be submitted

to the attention

of the COTR as provided below.

Peace Corps Office of Medical Services Attn: Christine Torbert

10

PC-11-P-AB07

111120th Street, N.W. Washington, DC. 20526 e-mail: ctorbert@peacecorps.gov Only those supplies/services specifically stated in this contract are authorized for delivery. of

Delivery of unauthorized products/services shall be at the risk of and the sole responsibility the supplier and may result in non-payment as well as cancellation of this contract.

In the event the Contractor anticipates difficulty in complying with any delivery dates, the Contractor shall immediately notify the Contracting Officer (and the COTR) orally and in writing giving pertinent details, including the date by which the Contractor expects to make delivery. This data shall be informational in nature and receipt thereof shall not be construed as a waiver by the Government of any schedule, rights, or remedy. Deliverable Table (reference Section C.4) Report Monthly Performance Summary Year-end Performance Summary Format Electronic Electronic Submittal Monthly (15th of each

month]
Annuallv(30 days after the close of each contract year)

END OF SECTION F

SECTION G - CONTRACT ADMINISTRATION DATA

G.1 Contract

Management

Notwithstanding the Contractor's responsibility for total management during the performance of this contract, the administration of the contract will require maximum coordination between the Peace Corps and the Contractor. be the Contractor's points of contact: The following individuals will

Contracting Officer (CO) - All contract administration will be effected by the CO. Communications pertaining to contractual administrative matters shall be addressed to the co. No changes in or deviation form the Statement of Work (SOW) shall be affected

11

PC-11-P-AB07

without a written changes.

modification

to the

contract/s executed by CO, authorizing such

Contracting Officers Technical Representative (CarR) - A carR will be assigned at the time of award of this contract. The carR will be given authority by the CO to monitor all technical aspects and assist in the administration of the contract. The type of action within the purview of the COTR authority are: to assure that the Contractor performs all the technical requirements of the contract; to perform or cause to be performed all inspections necessary in connection with performance of the contract; and to maintain both written and oral communications with the Contractor concerning the technical aspects of the requirements. The COTR shall monitor the Contractor's performance under the contract and notify the Contractor and the CO of any deficiencies observed, as well as to coordinate Government furnished property and provide for site entry of Contractor personnel if required. The CarR is NOT authorized to change any of the terms and conditions of this contract. Only the CO is authorized to make changes to the SOW, through a properly executed modification to the contract. The COTR is NOT authorized to re-delegate his/her authority. bring all such contractual problems to the immediate attention of the CO.

G. 2 TECHNICAL DIRECTIONS
(a) Technical Direction is defined to include: (1) Written directions to the Contractor which fill in details, suggest possible lines of inquiry, or otherwise facilitate completion of work; (2) Provision of written information to the Contractor which assists in the interpretation of drawings, specifications, or technical portions of the work statement; (3) Review and, where required, provide written approval of technical reports, drawings, specifications, or technical information to be delivered. Technical directions must be in writing, and must be within the scope of the work as detailed in Section C. (b) The Contracting Officer, by separate designation letter authorizes the carR to take any or all action with respect to the following which could lawfully be taken by the Contracting terms of this Contract: Officer, except any action specifically prohibited by the

(1) Assure that the Contractor performs the technical requirements of the contract in accordance with the contract terms, conditions, and specifications. (2) Perform or cause to be performed, inspections necessary in connection with a) above and require the Contractor to correct all deficiencies; perform

12

PC-11-P-AB07

acceptance for the Government. (3) Maintain all liaison and direct communications with the Contractor. Written communications with the Contractor and documents shall be signed as "COTR" with a copy furnished to the Contracting Officer. (4) Issue written interpretations of technical requirements drawings, designs, and specifications. of Government

(5) Monitor the Contractor's production or performance progress and notify the Contractor in writing of deficiencies observed during surveillance, and direct appropriate action to effect correction. Record and report to the Contracting Officer incidents of faulty or nonconforming work, delays or problems. (6) Obtain necessary security clearance and appropriate identification if access to Government facilities is required. If to be provided, ensure that Government furnished property is available when required. LIMITATIONS: The COTR is not empowered to award, agree to, or sign any contract (including delivery or purchase orders) or modifications thereto, or in any way to obligate the payment of money by the Government. The COTR may not take any action which may impact on the contract schedule, funds, scope or rates of pay. All contractual agreements, commitments, or modifications which involve prices, quantities, quality, and/or schedules shall be made only by the Contracting Officer. (c) In a separately-issued COTR designation letter, the CO designates an Alternate COTR to act in the absence of the designated CTO, in accordance with the terms of the letter. (d) Contractual Problems - Contractual problems, of any nature, that may arise during the life of the contract must be handled in conformance with specific public laws and regulations [i.e, Federal Acquisition Regulation). The Contractor and the COTR shall bring all contracting problems to the immediate attention of the Contracting Officer. Only the Contracting Officer is authorized to formally resolve such problems. The Contracting Officer will be responsible for resolving legal issues, determining contract scope and interpreting contract terms and conditions. The Contracting Officer is the sole authority authorized to approve changes in any of the requirements under this contract. Notwithstanding any clause contained elsewhere in this contract, the said authority remains solely with the Contracting Officer. These changes inetude, but will not be limited to the following areas: scope of work, price, quantity, technical specifications, delivery schedules, and contract terms and conditions. In the event the Contractor effects any changes at the direction of any other person other than the Contracting

13

PC-11-P-AB07

Officer, the change will be considered to have been made without authority. (e) Failure by the Contractor to report to the Administrative Contracting Office, any action by the Government considered to a change, within the specified number of days contained in FAR 52.243-7 (Notification of Changes), waives the Contractor's right to any claims for equitable adjustments. (f) In case of a conflict between this contract and the COTR designation letter, the contract prevails.

G.3 KEY PERSONNEL
At least 30 days prior to diverting any of the specified individuals to other programs or contracts (or as soon as possible, if an individual must be replaced, for example, as a result of leaving the employ of the Contractor), the Contractor shall notify the Contracting Officer and shall submit comprehensive justification for the diversion or replacement request (including proposed substitutions for key personnel) to permit evaluation by the Government of the impact on performance under this contract. The Contractor shall not divert or otherwise replace any key personnel without the prior written consent of the Contracting Officer (CO). The Government may modify the contract to add or delete key personnel at the request of the Contractor or deemed necessary by the Government. The following personnel have been identified as Key Personnel:

Name

Title

G.4 WITHHOLDING OF CONTRACT PAYMENTS Notwithstanding any other payment provision of this contract, faiture of the Contractor to submit required reports when due, orfailure to perform or deliver required services/supplies may result in the withholding of payments under this contract. Payments may be withheld unless such failure arises out of circumstances beyond the Contractor's control and without fault or negligence on the part of the Contractor, as provided for in the relevant contract clauses. The Peace Corps shall promptly notify the Contractor of its intention to withhold payment of any voucher or invoice in full; however, if only a portion(s) of the invoice are being withheld, then the voucher may be processed without notification to the Contractor to prevent delay in payment. G.S INTERPRETATION OF MODIFICATION No oral or written statement of any person and no written statement of anyone other than the CO shall modify or otherwise affect the terms or meaning or this contract. Requests for interpretations, modifications or changes must be made in writing to the

14

PC-11-P-AB07

co.

The COTR can only respond (verbally or in writing) to technical matters.

G.6 INVOICE REQUIREMENTS Present to PeaceCorps a detailed invoice for payment costs due the Contractor for services rendered under the Contract on a monthly basis beginning the month following the first month of service and every month thereafter. The invoice details will include, but not limited to the following: • • • • • • • • • • Name and address of the Contractor Invoice date and invoice number Period of performance covered by the invoice Contract Number Description, price(s) and quantity(ies) of services and supplies for which payment is being requested Shipping and payment terms, if any EFTaccount/payment information (see below) Costs incurred under the current voucher or costs incurred to date (cumulative) Signature of the Contractor's authorized representative Contractor's Tax Identification Number (TIN)

G.7 MANDATORY

INFORMATION

FOR ELECTRONIC FUNDS TRANSFER PAYMENT

(a) The Contractor is required, as a condition to any payment under this contract, to provide Peace Corps with the information required to make payment by Electronic Funds Transfer (EFT).Prior to submission of the first request for payment under this contract, the Contractor shall provide the following information on the form provided as an Attachment to this contract: (1) (2) Name, address, and 9-digit American Banking Association Routing Transit Number of the Contractor's financial institution; Contractor's account number and the type of account (checking, saving, or lockbox.).

(b) If the Contractor's financial institution is not directly on-line to the Federal ReserveWire Transfer System (i.e., stock brokerage, foreign bank, etc. and therefore, not the receiver

15

PC-11-P-AB07

of the wire transfer payment), the Contractor shall also provide the name, address and 9digit ABA Routing Transit Number of the correspondent financial institution (i.e., U.S. bank) receiving the wire transfer payment. (c) Notwithstanding the provisions of any other clause of this contract, Peace Corps is not required to make any payment under this contract until after receipt, by the designated payment office, of the correct EFTpayment information for the Contractor. Until receipt of the correct EFTinformation, any invoice shall be deemed not to be a valid invoice as defined in by FAR52.232-25, Prompt Payment. (d) If the EFTinformation changes after submission of correct EFTinformation, Peace Corps shall begin using the changed EFTinformation no later than the 30th day after its receipt to the extent payment is made by EFT. However, the Contractor may request that no further payment be made until the payment office implements corrected EFT information. If such suspension would result in a late payment under the Prompt Payment clause of this contract, the Contractor's request for suspension shall extend the due date for payment by the number of days of the suspension. (e) The Contractor shall designate a single financial agent capable of receiving and processing the electronic funds transfer using the EFTmethods described in paragraph (a) of this clause. The Contractor shall pay all fees and charges for receipt and processing of transfers.
(f)

If an uncompleted or erroneous transfer occurs because Peace Corps failed to use the Contractor-provided EFT information in the correct manner, Peace Corps remains responsible for-(i) Making a correct payment (ii) Paying any prompt payment penalty due; and (iii) Recovering any erroneously directed funds.

(g) If an uncompleted or erroneous transfer occurs because Contractor-provided EFT information was incorrect at the time of Government release of the EFT payment transaction instruction to the Federal ReserveSystemsand: (i) If the funds are no longer under the control of the payment office, Peace Corps is deemed to have made payment and the Contractor is responsible for recovery of any erroneously directed funds; or If the funds remain under the control of the payment office, Peace Corps retains the right to either make payment by mail or suspend the payment in accordance with

(ii)

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paragraph (c) of this clause. (h) A payment shall be deemed to have been made in a timely manner in accordance with the Prompt Payment clause of this contract if, in the EFTpayment transaction instruction given to the Federal ReserveSystem, the date specified for settlement of the payment is on or before the prompt payment due date, provided the specified payment date is a valid date under the rules of the Federal ReserveSystem. When payment cannot be made by EFT because of incorrect EFT information provided by the Contractor, no interest penalty is due after the date of the uncompleted or erroneous payment transaction; provided that the notice is issued to the Contractor within 7 days after Peace Corps is notified of the defective EFT information. If the Contractor assigns the proceeds of this contract as provided in by FAR32.304-5, Assignment of Claims, the assignee shall provide Peace Corps with the assignee EFT information in accordance with paragraphs (a) and (b) ofthis clause.

(i)

(j)

(k) If the Contractor does not wish to receive payment by EFT methods for one or more payment, the Contractor may submit a request to the designated payment office to refrain from requiring EFTinformation or using the EFTpayment method. The decision to grant the request is solely at the discretion of PeaceCorps. (I) The Contractor agrees that the Contractor's financial agent may notify Peace Corps of a change to the roLiting transit number, Contractor account number or account type, as if the Contractor provided it. Peace Corps shall use the changed data in accordance with this clause.

END OF SECTION G

SECTION H - SPECIALCONTRACT REqUIREMENTS H.l USE OF PEACECORPS NAME AND LOGO (NOVEMBER 2008)

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The Contractor shall make no publicity announcements promotional materials mentioning the Contractor's consulting with the Contracting Officer. name and/or logo in conjunction the Contracting Officer.

or issue other public relations or shall not use the Peace Corps logo, trademark,

connection with Peace Corps without first

Further, the Contractor

with, or proximity to, the Contractors

trade name or facsimile thereof (co-branding)

without the advance written concurrence of

H.2

PERSONAL SECURITY REQUIREMENTS-

PEACE CORPS NOVEMBER

2005 relationship,

It is the policy of the Peace Corps to exclude from engagement via contractual including subcontracts, or by way of contract.

any individuals who have engaged in intelligence activity or related

work or who have been employed by or connected with an intelligence agency either directly

H.3 PERSONNEL SECURITY CLEARANCES FOR ON-SITE CONTRACTOR PERSONNEL (JUL 2003) All contractor employees who will be required to work on-site at Peace Corps facilities must undergo personnel security processing consisting of, at a minimum, a National Agency Check (NAC). Companies assigning contract employees to positions requiring access to classified information will obtain security clearances for those employees through the Peace Corps, Office of Personnel Security, at no cost to the company. At the beginning of a contract or when new personnel are assigned to an existing contract, the Contractor will be required to submit a Personnel Security Questionnaire, Standard Form 86 to the Contracting Officers Representative (~OR). In addition, two copies of Form FD-258 (Contractor Fingerprint Cards) and a Fair Credit Reporting Act Release, will be furnished. All forms must be furnished to the COR three (3) business days prior to the contract employee reporting for duty. M/HRM/SEC will conduct expedited checks of selected information and if no disqualifying issues are discovered, will advise the Physical Security Office that an "interim" security clearance has been granted and that an identification badge may be issued to the contract employee. The interim security clearance will permit the contract employee to have access to classified information at the specified level (Confidential, Secret or Top Secret) as required in the performance of his/her duties and to work on-site prior to the completion of the investigation and the issuance of a final security clearance.

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If at any time during the course of the investigation, a disqualifying issue is discovered that could impact the approval of a contract employee's final security clearance, the interim security clearance will be withdrawn and the contract employee will be barred from unescorted access to Peace Corps facilities until the disqualifying issue can be resolved. If for any reason, at the sole discretion of the Office of Personnel Security, a contract employee's security clearance is denied, withdrawn or revoked, the Contractor shall immediately furnish a qualified contract employee to provide the services required under the contract. Those companies assigning contract employees to positions which will not require access to classified information will obtain site access authorizations for those employees through the Peace Corps, Office of Personnel Security, at no cost to the company. At the beginning of a contract, or when new personnel are assigned to an existing contract, the Contractor will be required to submit to the Contracting Officer's Representative (COR) the Personnel Security Questionnaire (SF-aS, SF-SSPor SF-S6) appropriate for the sensitivity of the position in which the contactor employee will work, in addition to two (2) copies of Form FD-258 (Contractor Fingerprint Cards) and a Fair Credit Reporting Act Release. All forms must be furnished to the COR three (3) business days prior to the time the contractor employee is expected to begin work. SECwill conduct expedited checks of selected information and if no issues are present, will notify the Office of Physical Security that a "No Objection Waiver" (NOW) has been granted and that a building pass may be issued to the employee. The NOW will permit the contractor employee to work on-site at Peace Corps facilities prior to the completion of the investigation and the issuance of final site access authorizations .: If however, during the course of the investigation, an issue is discovered that could impact on

the utilization of the contract employee on-site at Peace Corps facilities, the NOW will be withdrawn and the contractor employee will be bared from unescorted access to Peace Corps facilities until the precipitating issue can be resolved. If for any reason, at the sale discretion of the Peace Corps, the Office of Personal Security denies a contract employee a NOW or a final site access authorization; the contractor shall immediately furnish a suitable employee to provide the required services. At the end of a contractor employee's performance at the Peace Corps facility, whether at the end of the contract or during the period of performance, the contractor employee shall turn in his/her Peace Corps issued identification badge to the Office of Personnel Security prior to departure. The applicable Peace Corps Staffing Analyst for the COR will promptly

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remove the contractor employee from Peace Corps software tracking systems such as e-mail, Personnel Tracking System (PTS), etc. H.4 OBSERVANCE OF LEGAL HOLIDAYS AND ADMINISTRATIVE (a)(l) Peace Corps observes the following New Year's Day Memorial Day Columbus Day Christmas Day days as holidaysPresident's Day Labor Day Thanksgiving Day LEAVE (AUG 2002)

Martin Luther King's Birthday Independence Day Veteran's Day

Any other day designated by Federal law, Executive Order or Presidential Proclamation. (2) When any holiday specified in (a)(l) falls on a Saturday, the preceding Friday shall be observed. When any such holiday falls on a Sunday, the following Monday shall be observed. Observances of such days by Government personnel shall not be cause for additional period of performance or entitlement to compensation except as set forth in the contract. If the Contractor's personnel work on a holiday, no form of holiday or other premium compensation will be reimbursed either as a direct or indirect cost, unless authorized pursuant to an overtime clause elsewhere in this contract. (b){l) Peace Corps may close a Peace Corps facility for all or a portion of a business day as a result of(A) Granting administrative unanticipated holiday); (B) Inclement weather; {C}I Failure of Congress to appropriate (0) Or any other reason. (2) In such cases, Contractor personnel not classified as essential, i.e., not performing critical round-the-clock services or tasks, who are not already on duty at the facility shall not report to the facility. Such Contractor personnel already present shall be dismissed and shall leave the facility. (3) The Contractor agrees to continue to provide sufficient personnel to perform roundthe-clock requirements of critical tasks already in operation or scheduled for performance during the period in which Peace Corps employees are dismissed, and shall be guided by any specific instructions authorized representative. of the Contracting Officer or his/her duly operational funds; leave to non-essential Peace Corps employees (e.g.,

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END OF SECTION H

SECTION I - CONTRACT CLAUSES FAR 52.252-2 CLAUSES INCORPORATED BY REFERENCE (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address (es): http://acguisition.gov/far/index,html. FAR 52.202-1 FAR 52.203-5 FAR 52.203-7 FAR 52.204-7 FAR 52.212-1 FAR 52.212-4 FAR 52.224-2 FAR 52.232-1 FAR 52.232.-18 FAR 52.233-1 FAR 52.233-3 FAR 52.233-4 FAR 52.237-3 FAR 52.242-15 FAR 52.244-6 DEFINITIONS OF WORDS AND TERMS PROVISIONS AND CLAUSES ( JULY 2004) COVENANT AGAINST CONTINGENT ANTI-KICKBACK FEES (APRIL 1984)

PROCEDURES (OCT 2010)

CENTRAL CONTRACTOR REGISTRATION (APR 2008) INSTRUCTIONS TO OFFERORS-COMMERCIAL CONTRACT TERMS AND CONDITIONS PRIVACY ACT (APR 1984) PAYMENTS (APR. 1984) AVAILABILITY OF FUNDS (APR 1984) ITEMS (JUN 20OS) ITEMS (JUNE 2010)

COMMERCIAL

DISPUTES (JULY 2002) PROTEST AFTER AWARD (AUG. 1996) APPLICABLE LAW FOR BREACH OF CONTRACT CLAIM (OCT 2004) CONTINUITY OF SERVICES (JAN 1991)

STOP-WORK ORDER (AUG. 1989) SUBCONTACTS FOR COMMERCIAl,TEMS (DEC 2010)

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FAR 52.245~1GOVERNMENT

PROPERTY (AUG 2010) REQUIRED TO IMPLEMENT ITEMS (APR 2011) STATUTES OR

52.212~S CONTRACT TERMS AND CONDITIONS .EXECUTIVE ORDERS -- COMMERCIAL

(a) The Contractor shall comply with the following Federal Acquisition Regulation (FAR) clauses, which are incorporated in this contract by reference, to implement provisions of law or Executive orders applicable to acquisitions of commercial items: (1) 52.222-50, Combating Trafficking in Persons (FEB 2009) (22 U.S.c. 7104(g)). __ Alternate I (AUG 2007) of 52.222~50 (22 U.S.c. 7104(g)}.

(2) 52.233~3, Protest After Award (AUG 1996) (31 U.S.C. 3553). (3) 52.233-4, Applicable 108-77,108-78).

law for Breach of Contract Claim (OCT 2004) (Pub. l.

(b) The Contractor shall comply with the FAR clauses in this paragraph (b) that the contracting officer has indicated as being incorporated in this contract by reference to implement provisions of law or Executive orders applicable to acquisitions of commercial items:

_x_

(1) 52.203-6, Restrictions on Subcontractor Sales to the Government (Sept 2006), with Alternate I (Oct 1995) (41 U.S.C. 253g and 10 U.S.C. 2402).

_ (2) 52.203-13, Contractor Code of Business EthiCSand Conduct (Apr 2010) (Pub. l. 110-252, Title VI, Chapter 1 (41 U.S.c. 251 note)). _ (3) 52.203-15, Whistleblower Protections under the American

Recovery and Reinvestment Act of 2009 (Jun 2010) (Section 1553 of Pub l. 111-5) (Applies to contracts funded by the American Recovery and Reinvestment Act of 2009).

_x_

(4) 52.204-10, Reporting Executive compensation and First-Tier Subcontract Awards (Jul 2010) (Pub. L 109~282) (31 U.S,C. 6101 note).

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_ (5) 52.204-11, American Recovery and Reinvestment ActReporting Requirements (Jul 2010) (Pub. L 111-5). _ (6) 52.209-6, Protecting the Government' Interest When

Subcontracting with Contractors Debarred, Suspended, or Proposed for Debarment (Dec 2010) (31 U.S.C. 6101 note). (Applies to contracts over $30,000). (Not applicable to subcontracts for the acquisition of commercially available off-the-shelf items). _ (7) 52.219-3, Notice of Total HUBZone Set-Aside or Sole-Source Award (Jan 2011) (15 U.S.c. 6S7a). _ (8) 52.219-4, Notice of Price Evaluation Preference for HUBZone Small Business Concerns (Jan 2011) (if the offeror elects to waive the preference, it shall so indicate in its offer)(15 U.S.c. 657a). _ (9) [Reserved]

_x_
_ _

(10) (i) 52.219-6, Notice of Total Small Business Aside (June 2003) (15 U.S.c. 644).

(il) Alternate 1 (Oct 1995) of 52.219-6. (iii) Alternate II (Mar 2004) of 52.219-6.

_ (11) (i) 52.219-7. Notice of Partial Small Business Set-Aside (June 2003) (15 U.S.c. 644). _ (ii) Alternate I (Oct 1995) of 52.219-7.

_

(iii) Alternate 11(Mar 2004) of 52.219-7.

_ (12) 52.219-8, Utilization of (15 U.S.C. 637{d)(2) and (3)).

Small Business Concerns (Jan 2011)
Plan (Jan 2011)

_ (13) (i) 52.219-9, Small Business Subcontracting (15 u.s.c. 637 (d){4).) _ _ _ (ii) Alternate (iii) Alternate (iv) Alternate I (Oct 2001) of 52.219-9. II (Oct 2001) of 52.219-9. III (July 2010) of 52.219-9.

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_x_
_

(14) 52.219-14, Limitations on Subcontracting

(Dec 1996) (15

U.S.C. 637(a)(14)). (15) 52.219-16, Liquidated Damages-Subcontracting Plan (Jan

1999) (15 U.S.c. 637(d)(4)(F)(i)). _ {16} (i) 52.219-23, Notice of Price Evaluation Adjustment for

Small Disadvantaged Business Concerns (Oct 2008) (10 U.S.c. 2323) (if the offeror elects to waive the adjustment, it shall so indicate in its offer). _ (ii) Alternate I (June 2003) of 52.219-23.

_ (17) 52.219-25, Small Disadvantaged Business Participation Program-Disadvantaged Status and Reporting (Dec 2010) (Pub. L. 103-355, section 7102, and 10 U.S.c. 2323). _ (18) 52.219-26, Small Disadvantaged Business Participation Program-Incentive Subcontracting (Oct 2000) (Pub. L. 103-355, section 7102, and 10 U.S.c. 2323). _ (19) 52.219-27, Notice of Total Service-Disabled Veteran-Owned Small Business Set-Aside (May 2004) (15 U.S.c. 657 f).

_x_

(20) 52.219-28, Post Award Small Business Program Rerepresentation (Apr 2009) (15 U.S.c. 632(a)(2)).

_ (21) 52.219-29, Notice of Total Set-Aside for Economically Disadvantaged Women-Owned Small Business (EDWOSB) Concerns (Apr 2011). _ (22) 52.219-30, Notice of Total Set-Aside for Women-Owned Small Business (WOSB) Concerns Eligible Under the WOSB Program (Apr 2011). _X_ (23) 52.222-3, Convict Labor (June 2003) (E.C. 11755) .

..X_ _(24} 52.222-19, Child

Labor-Cooperation

with Authorities

and

Remedies (Jul 2010) lE.O. 13126).

___x_

(25) 52.222-21, Prohibition

of Segregated Facilities (Feb 1999).

24

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_x_

(26) 52.222-26, Equal Opportunity

(Mar 2(07) (E.O. 11246). for Veterans (Sep 2010) (38

_X_ (27) 52.222-35, Equal Opportunity U.S.C.4212). _lL (28) 52.222-36, Affirmative (Oct 2010) (29 U.S.c. 793).

Action for Workers with Disabilities

_!_ (29) S2.222':H, Employment Reports on Veterans {Sep l010}
(38 U.S.c. 4212). _ (30) 52.222-40, Notification of Employee Rights Under the National Labor Relations Act (Dec 2010) (E.O. 13496).

_x_ (31) 52.222-54,

Employment Eligibility Verification (Jan 2009). (Executive Order 12989). (Not applicable to the acquisition of commercially available off-the-shelf items or certain other types of commercial items as prescribed in 22.1803.)

_ (32) (i) 52.223-9, Estimate of Percentage of Recovered Material Content for EPA-Designated Items (May 2008) (42 U.S.c. 6962(c)(3}(AHii)). (Not applicable to the acquisition of commercially available off-the-shelf items.)

_

(ii) Alternate I (May 2008) of 52.223-9 (42 U.S.c. 6962(i}(2}(C).
available off-the-

(Not applicable to the acquisition of commercially shelf items.)

_ (33) 52.223-15, Energy Efficiency in Energy-Consuming (Dec 2007) (42 U.S.c. 8259b).

Products

_ (34) (i) 52.223-16, IEE£ 1680 Standard for the £nvironmental Assessment of Personal Computer Products (Dec 2007) (E.O. 13423).

_

(ii) Alternate I (Dec 2007) of 52.223-16.

_x_

(35) 52.223-18, Contractor Policy to Ban Text Messaging while Driving (Sep 2010) (E.O. 13513).

_ (36) 52.225-1, Buy American Act--Supplies (Feb 2009) (41 U.S.C. 10a-10d).

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_ (37) (i) 52.225-3, Buy American Act -Free Trade Agreements Israeli Trade Act (Jun 2009) (41 U.S.C. ioa-ioc, 19 U.S.C. 3301 note, 19 V.S.c. 2112 note, 19 U.S.c. 3805 note, Pub. L. 108-77. 108-78, 108-286, 108-301, 109-53,109-169, 109-283, and 110-138).

_
_ _

(Ii} Alternate I (Jan 2004) of 52.225-3.
(iii) Alternate II (Jan 2004) of 52.225-3.

(38) 52.225-5, Trade Agreements (Aug 2009) (19 U.S.C. 2501,

et

seo., 19 U.S.C. 3301 note).
_ (39) 52.225-13, Restrictions on Certain Foreign Purchases (Jun 2008) (E.O:s, proclamations, and statutes administered by the Office of Foreign Assets Control of the Department of the Treasury). _ (40) 52.226-4, Notice of Disaster or Emergency Area Set-Aside (Nov 2007) (42 V.S.c. 5150). _ (41) 52.226-5, Restrictions on Subcontracting Emergency Area (Nov 2007) (42 U.S.c. 5150). Outside Disaster or

_ (42) 52.232-29, Terms for Financing of Purchases of Commercial Items (Feb 2002) (41 255{f), 10 U.S.C. 2307(f)).

u.s.c.

_

(43) 52.232-30, Installment

Payments for Commercial Items (Oct

1995) (41 U.s.C. 255(f), 10 U.S.C. 2307(f)) .

.lL.. (44)

52.232-33. Payment by Electronic Funds Transfer-Central Contractor Registration (Oct. 2003) (31 U.S.C. 3332).

_ (45) 52.232-34, Payment by Electronic Funds Transfer-Other Than Central Contractor Registration (May 1999) (31 U.S.C. 3332). _ (46) 52.232-36, Payment by Third Party (Feb 2010) (31 U.S.c. 3332).

__jL (47) 52.239-1, Privacy or Security Safeguards (Aug 1996) (5
U.S.c. 552a).

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_ (48) (i) 52.247-64, Preference for Privately Owned U.S.-Flag Commercial Vessels (Feb 2006) (46 U.S.c. Appx 1241(b) and 10 U.S.c. 2631).

_

[ii) Alternate I (Apr 2003) of 52.247-64.

(c) The Contractor shall comply with the FAR clauses in this paragraph (c), applicable to commercial services, that the Contracting Officer has indicated as being incorporated in this contract by reference to implement provisions of law or executive orders applicable to acquisitions of commercial items: [Contracting _ 351, Officer check as appropriate.]

(1) 52.222-41, Service Contract Act of 1965 (Nov 2007) (41 U.S.C.

et seq.).

_ (2) 52.222-42, Statement of Equivalent Rates for Federal Hires (May 1989) (29 U.S.c. 206 and 41 U.S.C. 351, et seq.). _ (3) 52.222-43, Fair labor Standards Act and Service Contract Act - Price Adjustment (Multiple Year and Option Contracts) (Sep 2009) (29 U.S.C.20G and 41 U.S.c. 351, et seq.). _ (4) 52.222-44, Fair Labor Standards Act and Service Contract Act - Price Adjustment (Sep 2009) (29 U.S.C. 206 and 41 U.S.c. 351, et seq.). _ (5) 52.222-51, Exemption from Application of the Service Contract Act to Contracts for Maintenance, Calibration, or Repair of Certain Equipment--Requirements (Nov 2007) (41 U.S.C. 351, et seq.). _ (6) 52.222-53, Exemption from Application of the Service Contract Act to Contracts for Certain Services--Requirements (Feb 2009) (41 U.S.c. 351, et seq.). _ (7) 52.226-6, Promoting Excess Food Donation to Nonprofit Organizations. (Mar 2009) (Pub. L. 110-247). _ (8) 52.237-11, Accepting and Dispensing of $1 Coin (Sep 2008)

(31 U.S.C. 5112(p)(1)).

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(d) Comptroller General Examination of Record The Contractor shall comply with the provisions of this paragraph (d) if this contract was awarded using other than sealed bid, is in excess of the simplified acquisition threshold, and does not contain the clause at 52.215-2, Audit and Records -- Negotiation. (1) The Comptroller General of the United States, or an authorized representative of the Comptroller General, shall have access to and right to examine any of the Contractor's directly pertinent records involving transactions related to this contract. (2) The Contractor shall make available at its offices at all reasonable times the records, materials, and other evidence for examination, audit, or reproduction, until 3 years after final payment under this contract or for any shorter period specified in FAR Subpart 4.7, Contractor Records Retention, of the other clauses of this contract. If this contract is completely or partially terminated, the records relating to the work terminated shall be made available for 3 years after any resulting final termination settlement. Records relating to appeals under the disputes clause or to litigation or the settlement of claims arising under or relating to this contract shall be made available until such appeals, litigation, or claims are finally resolved. (3) As used in this clause, records include books, documents, accounting procedures and practices, and other data, regardless of type and regardless of form. This does not require the Contractor to create or maintain any record that the Contractor does not maintain in the ordinary course of business or pursuant to a provision of law. (e) (1) Notwithstanding the requirements of the clauses in paragraphs (a), (b), (c) and (d) of this clause, the Contractor is not required to flow down any FAR clause, other than those in this paragraph (e)(l) in a subcontract for commercial items. Unless otherwise indicated below, the extent of the flow down shall be as required by the clause(i) 52.203-13, Contractor Code of Business Ethics and Conduct (Apr 20lD) (Pub. L. 110-252, Title VI, Chapter 1 (41 U.S.c. 251 note)). (ii) 52.219-8, Utilization of Small Business Concerns (Dec 201D) (15 U.S.C. 637(d)(2) and (3)), in all subcontracts that offer further subcontracting opportunities. If the subcontract (except subcontracts

28

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to small business concerns) exceeds $650,000 ($1.5 million for construction of any public facility). the subcontractor must include 52.219-8 in lower tier subcontracts that offer subcontracting opportunities.

(Hi) [Reserved]
(iv) 52.222-26. Equal Opportunity (v) 52.222-35, Equal Opportunity 4212). (vi) 52.222-36, Affirmative 2010) (29 U.S.C. 793). (Mar 2007) (E.O. 11246). for Veterans (Sep 2010) (38 U.S.c.

Action for Workers with Disabilities (Oct

(vii) 52.222-40, Notification of Employee Rights Under the National Labor Relations Act (Dec 2010) (E.O. 13496). Flow down required in accordance with paragraph (f) of FAR clause 52.222-40. (viii) 52.222-41, Service Contract Act of 1965, (Nov 2007). (41 U.S.C. 351, et seq.) (ix) 52.222-50, Combating Trafficking in Persons (Feb 2009) (22 U.S.c. 7104(g». _ Alternate I (Aug 2007) of 52.222-50 (22 U.S.C. 7104(g)}.

(x) 52.222-51, Exemption from Application of the Service Contract Act to Contracts for Maintenance, Calibration, or Repair of Certain Equipment--Requirements (Nov 2007) (41 U.S.c. 351, et seq.) (xi) 52.222-53, Exemption from Application of the Service Contract Act to Contracts for Certain Services--Requirements (Feb 2009) (41 U.S.c. 351, et seq.) (xii) 52.222-54, Employment Eligibility Verification (Jan 2009).

(xiii) 52.226-6, Promoting Excess Food Donation to Nonprofit Organizations. (Mar 2009) (Pub. l. 110-247). Flow down required in accordance with paragraph (e) of FAR clause 52.226-6.

29

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(xiv) 52.247-64, Preference for Privately-Owned U.S. Flag Commercial Vessels (Feb 2006) (46 U.S.c. Appx 1241(b) and 10 U.S.c. 2631). Flow down required in accordance with paragraph (d) of FAR clause 52.247-64. (2) While not required, the contractor may include in its subcontracts for

commercial items a minimal number of additional clauses necessary to satisfy its contractual obligations.

52.209-5 CERTIFICATION REGARDING RESPONSIBILITY MATTERS( APR 2010)
(a)(1) The Offeror certifies, to the best of its knowledge and belief, that(i) The Offeror and/or any of its Principals(A) Are ( ) are not ( ) presently debarred, suspended, proposed for debarment, declared ineligible for the award of contracts by any Federal agency; (B) Have ( ) have not ( ), within a three-year convicted of or had a civil judgment period preceding this offer, been to obtain, or performing a public rendered against them for: commission of fraud or a violation of Federal or State antitrust theft, forgery, or

criminal offense in connection with obtaining, attempting (Federal, State, or local) contract or subcontract; bribery, falsification or destruction

statutes relating to the submission of offers; or commission of embezzlement,

of records, making false statements, tax evasion, violating

Federal criminal tax laws, or receiving stolen property (if offeror checks "have", the offeror shall also see 52.209-7, if included in this solicitation);

{C} Are{ } are not ( ) presently indicted for, or otherwise criminally or civilly charged
by a governmental entity with, commission of any of the offenses enumerated in paragraph (a)(1)(i)(B) of this provision; (D) Have ( ), have not ( ), within a three-year notified of any delinquent liability remains unsatisfied. (1) Federal taxes are considered delinquent apply: if both of the following criteria period preceding this offer, been Federal taxes in an amount that exceeds $3,000 for which the

(i) The tax liability is finally determined. The liability is finaJly determined if it
has been assessed. A liability is not finally determined determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally until all judicial appeal rights have been exhausted.

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(ii) The taxpayer is delinquent in making payment. A taxpayer is delinquent the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded. notice of deficiency, under I,R.C. §

if

(2) Examples.
(i) The taxpayer has received a statutory is not rights. (ii) The IRShas filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. § 6320 entitling the taxpayer to request a hearing with the IRSOffice of Appeals contesting the lien filing, and to further appeal to the Tax Court if the IRSdetermines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exerclsed all judicial appeal rights. (iii) The taxpayer has entered into an installment agreement terms. The taxpayer is not delinquent required to make full payment. (iv) The taxpayer has filed for bankruptcy protection. delinquent Code). (ii) The Offeror has ( ) has not ( ), within a three-year period preceding this offer, had one or more contracts terminated (2) "Principal," for default by any Federal agency. means an officer, director, owner, within a for the purposes of this certification, The taxpayer is not because enforced collection action is stayed under 11 U.S.C. 362 (the Bankruptcy agreement pursuant to I.R.C. § 6159. The taxpayer is making timely payments and is in full compliance with the because the taxpayer is not currently

6212. which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This

a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court

review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal

partner, or a person having primary management or supervisory responsibilities segment; and similar positions).

business entity (e.g., general manager; plant manager; head of a division or business

31

PC-11-P-AB07

This Certification

Concerns a Matter Within the Jurisdiction of an Agency of the United May Render the

States and the Making of a False, Fictitious, or Fraudulent Certification

Maker Subject to Prosecution Under Section 1001, Title 18, United States Code. (b) The Offeror shall provide immediate written notice to the Contracting Officer if, at any was erroneous when

time prior to contract award, the Offeror learns that its certification (c) A certification certification responsibility. information

submitted or has become erroneous by reason of changed circumstances. that any of the items in paragraph (a) of this provision exists will not of an award under this solicitation. with a determination However, the of the Offeror's necessarily result in withholding

wfll be considered in connection

Failure of the Offeror to furnish a certification

or provide such additional of a

as requested by the Contracting Officer may render the Offeror nonresponsible. required by paragraph (a)

(d) Nothing contained in the foregoing shall be construed to require establishment system of records in order to render, in good faith, the certification of this provision. The knowledge and information

of an Offeror is not required to exceed that of fact

which is normally possessed by a prudent person in the ordinary course of business dealings.

(e) The certification

in paragraph (a) of this provision is a material representation

upon which reliance was placed when making award. If it is later determined knowingly rendered an erroneous certification, Government, solicitation for default. the Contracting Officer may terminate

that the Offeror

in addition to other remedies available to the the contract resulting from this

FAR 52.217-8

-- OPTION TO EXTEND SERVICES (NOV 1999)

The Government may require continued performance of any services within the limits and at the rates specified in the contract. These rates may be adjusted only as a result of revisions to prevailing labor rates provided by the Secretary of labor. The option provision maybe exercised more than once, but the total extension of performance hereunder shall not exceed 6 months. The Contracting Officer may exercise the option by written notice to the Contractor within 14 days. FAR 52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

32

PC-11-P-AB07

(a) The Government Contractor within preliminary written

may extend the term of this contract by written

notice to the

14 days; provided that the Government gives the Contractor a
notice of its intent to extend at least 30 days before the contract notice does not commit the Government to an extension. exercises this option, the extended contract shall be considered to

expires. The preliminary (b) If the Government

include this option clause. (c) The total duration of this contract, including the exercise of any options under this clause, shall not exceed 66 months. FAR 52.233-2 SERVICE OF PROTEST (SEP 2006)

(a) Protests, as defined in section 33.101 of the Federal Acquisition Regulation, that are filed directly with an agency, and copies of any protests that are filed with the Government Accountability Office (GAO), shall be served on the Contracting Officer (addressed as follows) by obtaining written and dated acknowledgment of receipt from: Peace Corps OACM Attn: Sandra Harrell 111120th St, NW. Washington, DC. 20526 (b) The copy of any protest shall be received in the office designated above within one day of filing a protest with the GAO.

END OF SECTION I

33

PC-11-P-AB07

SECTION J - LIST OF DOCUMENTS, LIST OF ATTACHMENTS:

EXHIBITS AND OTHER ATTACHMENTS

Attachment Attachment Attachment

2:
3:

1:

Dental Technical Guidelines Dental Exam Form Dental Report Format

End of Section J

34

ATTACHMENT 1 DENTAL TECHNICAL GUIDELINES

Peace Corps Technical Guideline 180

DENTAL POLICY
1. PURPOSE The purpose of this guideline is to outline the pre-service, in-serv ice and post-service components of the Peace Corps dental program. 2. BACK GROUND Dental problems are one of the most common in-service health problems for Volunteers and are a leading cause of medical evacuations (medevacs) and post-service Federal Employees' Compensation Act (FECA) claims. Many Volunteers serve in areas with limited or no access to dental facilities. The pre-service dental evaluation is handled by the appJicant's dentist. The in-service dental program will provide: • • • • Support for preventive dental hygiene to maintain dental hea1th; Restorative care for dental problems that arise during service;. A dental exam at Close of Service (COS); Routine dental prophylaxis (dental cleaning) at COS.

The post-service dental program will provide: • • Evaluation of service-related dental conditions; Treatment for service-related dental conditions under FECA.

3. PRE-SERVICE 3.1 Pre-ServiceDotal Oearance The applicant is examined by a dentist of his/her choice and any recommended dental treatment is performed, The dentist then completes the Report of Dental Examination, Form PC-1790 (Dental) ATTACHMENT A and sends it with a complete set of dental x-rays to the Office of Medical Services (OMS).

Office of Medlcol Services

May 201 J

Pagel

Denial Policy

TG180

The Report of Denta1 Examination and x-rays are maintained in the Volunteer's health record.

Offiu of Medical Services

May20J}

Pagel

TG180 DentolPolicy

4 IN-SERVICE

DENTAL PROGRAM

4.1 Prevention Good dental hygiene is known to reduce the incidence of decay. Dental hygiene must be emphasized in both initial and continuing health education programs. The following dental hygiene techniques should be stressed to Volunteers:
• Brush at least twice daily with good quality fluoride toothpaste.

• •

Floss at least once daily. Exercise caution when eating foods that may have foreign objects that could chip or otherwise damage teeth.

Toothpaste, toothbrushes, and dental floss are provided either through the VoJunteer living allowance or supplied through the health unit. 4.2 Mid-Service Dental Examination and Prophylaxis

Peace Corps supports an annual dental check-up (including prophylaxis and bitewing xrays) when there is a qualified dentist or dental hygienist identified at post. The midservice dental examination has two objectives: 1. Routine dental cleaning;
2. Identification and treatment of early disease. Medical evacuation (medevac) is not authorized fur the purposes of providing an

annual dental check-up. However. dental care, including an annual check-up, while in the U.S. on personal business may be authorized through the use of the PC-127C "Authorization of Payment ofMedicailDental Services" (see section 6 below). The rationale for annual versus semiannual dental examination and prophylaxis is outlined
below.

Many dentists in the United States recommend a dental exomination and prophylaxis every six months. However, professional dental organizations do not specify the frequency of prophylaxis for individuols with healthy pertodonua. The American Dental Assoctanon (ADA) recommends "periodic dental examinat;ons. " The ADA has no policy regarding the frequency of those exams. The U.S. Preventive Services Tasks Force. the preeminent source of preventive health recommendations in the US, states that "there is little evidence that annual or semiannual dental check-ups are necessary for persons without clinical evidence of dental disease. " Additionally, there is no scientific evidence to support the premise thai sem;-annual prophylaxis verses less frequent prophylaxis has any longterm benefit on dental health. Multiple studies have shown that in

()jJia of Medical Services

May 1011

Page 3 .

TG 180

De"'al Policy

indiViduals with healthy periodomta. annual scaling is as effective as m<)refrequent scaling in maintaining periodontal health. There is strong evidence that tooth brushing and flossing are effectWe means of maintaining periodontal health.

Individuals with active periodontal disease identified by a dentist may require more frequent exams and scaling, 10 these cases Peace Corps supports and provides all necessary care. However, for Volunteers In good dental health. the Peace Corps dental policy of annual examinations and prophylaxis, where available, is medically sound. Dental examinations and preventive care (cleaning and scaling) offered in country are often limited. However, most dentists are able to identify and treat asymptomatic caries. When available, cleaning and scaling should be performed annually. Unless the 100al dental care is unacceptable for even simple examination and treatment. all Volunteers should have a mid-service dental examination. 4.3 In-Country Management of Dental Problem.s General Principles The dental care available in country is frequently limited and restorative work may need to be redone after COS. This is partit:ularly true for crowns, root canal fillings, and bridge work. h is often in the Volunteer's interest to delay treatment untiJ after COS (see section 8 below). Peace Corps does not provide dental care to treat aesthetic conditions, e.g. orthodontia. dental veneers, or whitening procedures, or to correct pre-existing structural problems, e.g., malocclusion.
AUtIiorizing Dental Care


AU treatments except for routine check-ups, cleaning, and small fillings require prior authorization from the OMS dental consultant.
In general, the minimum restorative dental work possible should be done in

country. • Non-destructive, temporary procedures should be used whenever possible, thereby allowing definitive treatment to be carried out after COS. For example, it may be preferable to have a large filling done in country rather than a crown. A crown could be applied after return to the U.S. Treatment to correct a pre-existing aesthetic problem is not authorized by Peace
Corps and is not allowed in country.

Offi~ oj Medical Se1vicea

May 201 I

Page 4

TG ISO DenIal Policy

• •

Treatment to replace pre-existing missing teeth is not authorized by Peace Corps and is not allowed in country. Medevac is not authorized for the purposes of providing routine preventive dental
care.

Muagemeot

of Dental Problems

A Volunteer who requires, or is requesting, dental treatment may be referred to a

local dentist. The dentist will provide a diagnosis, treatment plan and estimated cost of the treatment in writing. • In all cases, except when a smalJ filling is required, details of the treatment plan and cost should be sent, via a field consult through the me, to the OMS dental consultant who will advise on the best course of action.
The dentaJ consultant wilt advise one of the following three options:

» Treatment can be deferred until COS.
)- A temporary procedure should be carried out.

»

A restorative procedure is required. The dental consultant win determine if the procedure can be done in country or requires medevac (regional or U.S.)

How to Contact tbe OMS Dental Conlulta»t In urgent cases, e.g., trauma, dental infections or linrOOlitting pain: • Send a fax or other electronic means to OMS. Include the patient's symptoms, the treating dentist's diagnosis, treatment plan and estimated cost of the treatment, as well as expected COS date.

In non-urgent cases:

Send a fax or other electronic means to OMS as. outlined above. Mail or pouch the pre-service x-ra) current x-rays and a copy of the pre-service FOnD PC-1790 (Dental) to OMS. This provides the dental consultant with adequate information to evaluate the case.

Except in emergencies, the denta1 consultant's response is required before authorizing treattnent. 5. ASSESSING IN-COUNTRY DENTAL SERVICES Volunteers must only be sent to a dentist whose services have been assessed by the PCMO. In addition to Qbtaining report'& from previous patients, a visit to the dental office is generally required. The PCMO should consider the following factors when assessing dental services.

Office o/Medical Services

May20IJ

PageS

TG180 Dental Policy

Sterilization

and Anti-Sepsis Practiees

• • • •

New disposable gloves, mask, needles and syringes and anesthetic ampules must be used for each patient. An adequate stock must he seen. Instruments must be autoclaved between patients. All surfaces must be disinfected between patients. Shie\ding for denta1 x-rays should be available (see TG 350 "Use of Medical X-Rays").
See TO 260 "Infection Control" for additional infonnation on infection Control practices.

Dental Technique

• • • •

Look at x-rays of previous root canal treatments. The tooth should be filled to within one millimeter of its tip. Assess how crowns fit on a dental model, the crown should be flush with the finish line of the prepared tooth. Ask previous patients if they are satisfied with the service they received. A thorough dental cleaning and scaling by a skilled dental technician typically takes 30· 45 minutes. In most Peace Corps countries. only limited dental cleanings are performed.

6. DENTAL EXAMS AND TREATMENT IN THE V.S. WHILE ON LEAVE • Volunteers may have elective dental work done in the U.S. while on leave. A PC~127C may be issued by the PCMO as per Technical Guideline 340 "PC-127C Fonn 'Authorization for Payment of MedicaJ/DentaJ Services':' Unless previously authorized by the OMS dental consultant, only evaluation and simple treatments should be authorized. PCMOs shouJd instruct the Volunteer to contact OMS if more complex care is required. For mid-service dental examinations the 127C should read:
"For dental examination, routine prophylaxiS, and treatment of caries only. Contact the OffICe of Medical Servlces if addltional dental treatment is required.~

There. are two options for payment/reimbursement

for care authorized by a 127C:

I. The dental provider accepts the 127C and submits a claim to the Peace Corps Health Benefit Program. This is the preferred method. 2. The Volunteer pays for the medical care and submits a claim for reimbursement to the Peace Corps Health Benefits Program. This information, including all necessary documentation for submitting a claim. is highlighted in red, hold type in the center of the J 27C.

Office of Medical Services

May 2011

Poge6

TGJ80 Denial Policy

• • •

Claims submitted to the Peace Corps Health Benefits Program will be reimbursed according to the Peace Corps Health Benefits fee schedule only. Prior to receiving care, the Volunteer should read and understand the infonnation on payment/reimbursement for medical care authorized by a 127C, AU 127C authorizations should be submitted to the Peace Corps Health Benefits Program for payment Of reimbursement. This includes 127Cs issued by post or by OMS, 127Cs issued for use in the U.S. or overseas, and ]27Cs issued for use during service or after
COS.

7. COS EXAMINATIONS • • • Refer to TO 330 "Post-Service Health Benefits and Close of Service and Extension of Service Health Evaluations.'; Dental examinations and bite-wing x-rays are provided for all Volunteers jf 12 or more months have elapsed since their pre-service dental examination. Dental examinations should be performed in~country, whenever possible. Simple denta1 treatments. such as fillings and cleanings, can be performed at this time. More complex procedures should generally be done after COS, unless excellent and affordable incountry services are available. The dents] examination and any treatments provided should be recorded by the examining dentist on form PC-1790 (Dental). If qualified dental care is not available \n ~untry, a. dental examtnat\01\ may be . authorized through a 127C. This authorization should read:
~For dental examination and routine prophylaxis only (including bite-Wing x-rays and other views 8S I'ldicated)." Note; If dental treatment is indicated please describe in detail and estimate cost or write on authorization "No tr.atment is authorized at this time."

• •

S. DOClJM.ENJ'ATION OF DENTAL CARE The PC-I 790 (Dental) form must be used for all pre-service and COS dental examinations. Mid-service use of the PC-1790 (Dental) fonn is encouraged but not required. The dentist's office documentation of the mid-service exam is acceptable ifit is accurate and complete. 9. POST·SERVICE DENTAL BENEFITS 9.1 Evaluation Evaluation of service-related dental conditions are authorized using a 127C. This authorization is valid for 180 days post-service and does not authorize treatment. If
Office c1f Medicm Senices
May 2011

Page?

TO rso
Dental Policy

indicated at COS. PCMOs may issue a 127C for specific dental evaluation. When a service-related dental problem arises within 180 days after COS the Post-Service Unit wm also issue an authorization. 9.2 Treatment Dental benefits are available under FECA. The Department of Labor (DOL) administers FECA. The DOL authorizes the OMS Post-Service Unit to manage claims less than $1,000. Both the DOL and the Post-Service Unit use dental x-rays and documentation 'maintained in the Volunteer heahh record to precess claims.

Office of Medical Sen/eel

May zou

PageS

ATTACHMENT 2 DENTAL EXAM FORM

Peace Corps
Report of

Dental Evaluation
PEAC£ CORPS US; ONLY
Check one:

N.me:

(Last. I=irst. Middle

IniLi'!)

Social Security number

Oat. of birth

I

[Me f OAY t VIl)

I

I

a
[;)

Pre-servi(e
Potot-ller'lice

.0

d~ntal exam dental ex~m

~on.-/p.rlnllnent add,.»

Other (pllKlie s~jf!l}

TelephoneNo. (

:

]

The infoJ1'll(ltion requesl:ad is collected undar the authority of the Peace Corps Act, 22 U.s.C. 2501 at seq, for the purpose of determining eligibility of Pwce Corps service and of documenting the boais for requested payments. Disclosure of this information is voluntary, but fa~ure to do 50 will make it impossible for the Peace Corps to pay for these WNitfl. Tllis iniofmation may lie used tor the routine U$es described in the Privocy Act. 5 USC 552Q, ond in the Federal Regider at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 I=ed.Reg. 1950, 1962 (January 14, 1985} regarding the Peace Corps system of records PC·17 (Volunteer recor<4). It may also be subject to the Health Insurance Portabirlty and Accountability Act (I-IIPAA) and current effective authorizations.

I. General Dental Gvaluation

I

Oat. of eMm

.

=

(1'010 I DAY I VII)

I

I

A. Chart existing restorations, Missing >t.. th and endodontically treated teeth=

Q

Check here if no existing restorations, missing teeth or endodontically treated teeth

OR
Comment on finding$:

8. Chart disease$,.abnormalities and ,It recommended treatments: >(All treatmenb neceslCllll at the time eWl(uaticm must he

0/ th.

charted here.)

o
OR

Check here if no disease, abnormality
or re<:ommended treatment

Comment on findings:

II. Periodontal Evaluation
A. Chart periodontal probings. gingival recession, and mobility
81;«:01

Pocket Depth
Depth
2

Ungual Poc~t

Buc.cal Recession

"

II

I

7

I

I

10

11

111

13

I"

IS

11

Lingual ~I!~ssion

lingual

Rl!CeSlion

Bucca! Recession

ao
lingual

_

11

POCKet Depth

Buccal Pocket Depth

Calculus OepO$its:

a

Light

o
teeth,

ModMate

Cl Heavy

B. Identify by number all teeth with:
Areas of bleeding upon probing Areas of suppuration Furcation involvement

a None
a None a None

o Affec::ted

-

_

o Affededteeth: o Affededteeth:
Q Affected teeth,
_

__
_

Insufficil!nt cttoched

gingiva

Q None

C.

Periodont.1 Classification:

a

No Dise<:lse

o Closs

1:.GinIJivitis Periodontitis Periodontitis

IJ. Ck;.ss til Em'ly

Q Class 1111 Maderote

Q Class M Advonced Periodontitis

O. Recommend.d periodontal ther!P}'l

~:
III. Third Molar Iivaluatlon
A.

!J

No history of pericoronitis

Q History

of

pericoronitis

Please provide dateS! Q Third molar extraction Q Third molar extraction not recommended recommended extractiQflS;

Please ~pecifY recommended

IV. TMJ 'valuation

o o

No history of TMD ~istory of TMD symptoms Please describe treatment

proviclecl, dates, and if 5ymptQJJ1S are present at this time:

Y.. Bruxism

a

No history of bruxism Plf!fUe describe any bruxism habit, presence of wear /aeets or nf*:d for or:;clu$ol guard,

Q I4lstory of bruxism

VI. Prosthesis

o
o

No prosthesis Prosthesis

present

present prosthesis (e.g., full or portial dentures, bridge, etc.)

Please describe the nature and extent of the
and the need for repair or replacement:

VII. Treatment
List all treatment Treatment completed after this examination. Do not include treatment Dote Completed planf'led but not yet completed. Signature of o.ntist

PeiICe C"rps . Report

Df

Dental E~amlnation

D·ental examination is complete only
·1
of the c.M.rtio:li!, {orin.

when:

INCOMPLETE FORMS WILL BE RETURNED AND MAY DELAY PROCESSING!

The dentist has ·completed·aU sections

2 3 4

The dentist has signed and deted the form,
The dentist has listed ali treatments in Section VII, . ....
::the

completed .:

Dordill's signa~lJre Dole

following setso] X-raY$:

de~rlsth~5 induded

o~e of the
..

1>

A full mouth serias, or ....

Dentist',
be

license number

State

. . ~) A P~nore)( with

Bitewing X.rays. mustbe than· .... one~arord. . All films must be original films, not"duplicates,' .

bitewing X·rays: Pe,rJapical P~norex films must less than two years old.

or

less

Note,
.

High quality

digital "lttrays can be accepted.
in a prote~tive cover,

Dentist's

"Q"lIt,

"ddress and phone number

All CDs must be su~.tted

.,.. Close-of.service only: .. ..The dentist has included bitewing X-i-ays.

FOR PEACE CORPS USE ONLY )J. Offiee of Medical Services Denial Consultant·

Dental aearanee

Noles, and Recommendations

o

Dental Clearance Pending
Reason for Pending:

Date

o

Dental Clearance

Oat.

LJ Dental Clearance

with Restrictions

Specify restrictions:

Signature

Date

ATTACHMENT 3 DENTAL REPORT FORMAT

.... 0

....

....

I
" 1
"V

~ ~

6

II[

re

.ffl
~

II

1/
~

U-

CD

f£'

II I a

f

a(
~

I

~ ~

Sl.

1

rc

I :s
~

I ,..
~

I
III

I II a II If I II rc II i :1 I I I I Sf II I ! 8fC

1
a. ..... ~

i
i

»
0

i

."

."

0

2

t a
{f
0 ...... CD

(

U-

!if'

rc

I~ n

CD

sc

n

I(

CD

ff fC

9.

a

fC If II a I i II

11

ff

Ii II Sl

f

fe

~ ~

~

e
g

i

i

3 3 ID

---~----'19 I

I:D

I!,.

~
0

f
i
.,

I i
:::a;
::a;
-,:I ft

rg ~

a

! .,
~

i
i
c

..

PC-11-P-AB07

SECTION K - REPRESENTATIONS. FAR S2.212-3-0fferor Representations

CERTIFICATIONS AND OTHER STATEMENTS Items. (APR 2011)

and Certifications-Commercial

An offeror shall complete only paragraphs (b) of this provision if the offeror has completed the annual representations and certificates electronically at http://orca.bpn.gov . If an offeror has not completed the annual representations and certifications electronically at the ORCA website, the offeror shall complete only paragraphs (c] through (o) of this provision. (a)

Definitions. As used in this provision--

"Economically disadvantaged women-owned small business (EDWOSB) concern" means a small business concern that is at least 51 percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States and who are economically disadvantaged in accordance with 13 CFR part 127. It automatically qualifies as a women-owned small business eligible under the WOSB Program. "Forced or indentured child labor" means all work or service-

(I) Exacted from any person under the age of 18 under the menace of any penalty for its nonperformance and for which the worker does not offer himself voluntarily; or
(2) Performed by any person under the age of 18 pursuant to a contract the enforcement of which can be accomplished by process or penalties. "Inverted domestic corporation" means a foreign incorporated entity which is treated as an inverted domestic corporation under 6 U.S.C. 395(b), i.e., a corporation that used to be incorporated in the United States, or used to be a partnership in the United States, but now is incorporated in a foreign country, or is a subsidiary whose parent corporation is incorporated in a foreign country, that meets the criteria specified in 6 U.S.c. 39S(b), applied in accordance with the rules and definitions of 6 U.S.C. 395{c}. "Manufactured 9999, exceptend product" means any end product in Federal Supply Classes (FSC) 1000·

{I} FSC5510, Lumber and Related Basic Wood Materials;
(2) Federal Supply Group (FSG) 87, Agricultural (3) FSG 88, live Animals; Supplies;

35

PC-11-P-AB07

(4) FSG89, Food and Related Consumables; (5} FSC9410, Crude Grades of Plant Materials; (6) FSC9430, Miscellaneous Crude Animal Products, Inedible; (7) FSC9440, Miscellaneous Crude Agricultural (8) FSC9610, Ores; (9) FSC9620, Minerals, Natural and Synthetic; and (10) fSC 9630, Additive Metal Materials. "Place of manufacture" means the place where an end product is assembled out of components, or otherwise made or processed from raw materials into the finished product that is to be provided to the Government. If a product is disassembled and reassembled, the place of reassembly is not the place of manufacture. "Restricted business operations" means business operations in Sudan that include power production activities, mineral extraction activities, oil-related activities, or the production of military equipment, as those terms are defined in the Sudan Accountability and Divestment Act of 2007 (Pub.l.ll0-174). Restricted business operations do not include business operations that the person (as that term is defined in Section 2 of the Sudan Accountability and Divestment Act of 2007) conducting the business can demonstrate(1) Are conducted under contract directly and exclusively with the regional government of southern Sudan; (2) Are conducted pursuant to specific authorization from the Office of Foreign Assets Control in the Department of the Treasury, or are expressly exempted under Federal law from the requirement to be conducted under such authorization; (3) Consist of providing goods or services to marginalized populations Sudan; (4) Consist of providing goods or services to an internationally peacekeeping force or humanitarian organization; of and Forestry Products;

recognized

(5) Consist of providing goods or services that are used only to promote health or education; or

36

PC-11-P-AB07

(6) Have been voluntarily "Service-disabled veteran-owned

suspended.

small busmess concern"-

(1) Means a small business concern(i) Not less than Sl percent of which is owned by one or more service-disabled veterans or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more service-disabled veterans; and

(ii) The management and daily business operations of which are controlled by one or more service-disabled veterans or, in the case of a service-disabled veteran with permanent and severe disability, the
spouse or permanent caregiver of such veteran. (2) Service-disabled veteran means a veteran, as defined in 38 U.S,"C.101(2), with a disability that is service-connected, as defined in 38 U.S.C 101(16). "Small business concern" means a concern, including its affiliates, that is independently owned and operated, not dominant in the field of operation in which it is bidding on Government contracts, and qualified as a small business under the criteria in 13 CFR Part 121 and size standards in this solicitation. "Veteran-owned small business concern" means a small business concern(1) Not less than 51 percent of which is owned by one or more veterans(as defined at 38 U.S.C. 101(2» or, in the case of any publicly owned business, not less than 51 percent of the stock of which is owned by one or more veterans; and (2) The management and daily business operations of which are controlled one or more veterans. by

"Women-owned business concern" means a concern which is at least 51 percent owned by one or more women; or in the case of any publicly owned business, at least 51 percent of the its stock is owned by one or more women; and whose management and daily business operations are controlled by one or more women. "Women-owned small business concern" means a small business concern --

37

PC-11-P-A607

(1) That is at least 51 percent owned by one or more women or, in the case of any publicly owned business, at least 51 percent of the stock of which is owned by one or more women; and (2) Whose management and daily business operations are controlled or more women. by one

"Women-owned small business (WOSB) concern eligible under the WOSB Program (in accordance with 13 CFR part 127)," means a small business concern that is at least Sl percent directly and unconditionally owned by, and the management and daily business operations of which are controlled by, one or more women who are citizens of the United States.

(b)
(1} Annual Representations and Certifications. Any changes provided by the offeror in paragraph (b}(2) of this provision do not automatically change the representations and certifications posted on the Online Representations and Certifications Application (ORCA} website. (2) The offeror has completed the annual representations and certifications

electronically via the ORCA website at http:Uorca.bpn.gov .After reviewing the ORCA database information, the offeror verifies by submission of this offer that the representation and certifications currently posted electronically at FAR 52.212-3, Offeror Representations and CertificationsCommercial Items, have been entered or updated in the last 12 months, are current, accurate, complete, and applicable to this solicitation (including the business size standard applicable to the NAICS code referenced for this solicitation), as of the date of this offer and are incorporated in this offer by reference (see FAR4.1201}, except for paragraphs . [Offeror to identify the applicable paragraphs at (c) through (0) of this provision that the offeror has completed for the purposes of this solicitation only, if any. These amended representation(s) and/or certlficationts} are also incorporated in this offer and are current, accurate, and complete as of the date of this offer. Any changes provided by the offeror are applicable to this solicitation only, and do not result in an update to the representations and certifications posted on ORCA.] (c] Offerors must complete the following representations when the resulting contract is to be performed in the United States or its outlying areas. Check all that apply.

38

PC-11-P-AB07

{l} Small business concern. The offeror represents as part of its offer that it
[_] is,

U is not

a small business concern.

{2} Veteran-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (cH1) of this provision.] The offeror represents as part of its offer that it U is, LJ is not a veteran-owned small business concern.

(3) Service-disabled veteran-owned small business concern. (Complete only if the offeror represented itself as a veteran-owned small business concern in paragraph (cHZ) of this provision.] The offeror represents as part of its offer that it U is, U is not a service-disabled veteran-owned small business concern. (4) Small disadvantaged business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (cHi} of this provision.] The offeror represents, for general statistical purposes, that it Ll is, U is not, a small disadvantaged business concern as defined in 13 CFR 124.1002. (5) Women-owned small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (c)(1) of this provision.] The offeror represents that it U is, [_J is not a women-owned small business concern. Note: Complete paragraphs (cH8) and (c)(9) only if this solicitation expected to exceed the simplified acquisition threshold. is

(6) WOSB concern eligible under the WOSB Program. [Complete only if the offeror represented itself as a women-owned small business concern in paragraph (c)(S) of this provision.] The offeror prepresents that(i) It U is, U is not a WOSB concern eligible under the WOSB Program, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and

Iii) It L] is, L1 is not a joint venture that complies with the requirements of 13 CFR part 12.7, and the representation in paragraph (c)(6){i) of this provision is accurate in reference to the WOSB concern or concerns that are participating in the joint venture.

39

PC-11-P-AB07

[The offeror shall enter the name or names of the waSB concern or concerns that are participating in the joint venture: WaSB concern participating in the joint venture shall submit a separate signed copy of the WaSB representation. (7) Economically disadvantaged women-owned

.J Each

small business (EDWaSB)

concern. [Complete only if the offeror represented itself as a WaSB concern eligible under the WaSB Program in (c)(6) of this provision.] The offeror represents that(i) It [_] is, U is not an EDWaSB concern eligible under the waSB Program, has provided all the required documents to the WOSB Repository, and no change in circumstances or adverse decisions have been issued that affects its eligibility; and

(ii) It U is, U is not a joint venture that complies with the requirements of 13 CFR part 127, and the representation in paragraph (c)(7)(ii) of this provision is accurate in reference to the
EDWOSB concern or concerns that are participating in the joint venture. The offeror shall enter the name or names of the EDWOSB concern or concerns that are participating in the joint venture: ______ . Each EOWOSB concern participating in the joint venture shall submit a separate signed copy of the EDWOSB representation. (8) Women-owned business concern (other than small business concern). [Complete only if the offeror is a women-owned business concern and did not represent itself as a small business concern in paragraph (c)(l) of this provision.]. The offeror represents that it U is, a women-owned business concern. (9) Tie bid priority for labor surplus area concerns. bid, small business offerors may identify the labor costs to be incurred on account of manufacturing or first-tier subcontractors) amount to more than price: If this is an invitation for surplus areas in which or production (by offeror 50 percent of the contract

(10) [Complete only if the solicitation contains the clause at FAR 52.219-23, Notice of Price Evaluation Adjustment for Small Disadvantaged Business

40

PC-11-P-AB07

Concerns, or FAR 52.219-25, Small Disadvantaged Business Participation Program-Disadvantaged Status and Reporting, and the offeror desires a benefit based on its disadvantaged status.]

(i) General. The offeror represents that either(A) It [_] is, U is not certified by the Small Business Administration as a small disadvantaged business concern and identified, on the date of this representation, as a . certified small disadvantaged business concern in the CCR Dynamic Small Business Search database maintained by the Small Business Administration, and that no material change in disadvantaged ownership and control has occurred since its certification, and, where the concern is owned by one or more individuals claiming disadvantaged status, the net worth of each individual upon whom the certification is based does not exceed $750,000 after taking into account the applicable exclusions set forth at 13 CFR 124.104(c)(2}; or (B) It [_] has, L1 has not submitted a completed application to the Small Business Administration or a Private Certifier to be certified as a small disadvantaged business concern in accordance with 13 CFR 124, Subpart B, and a decision on that application is pending, and that no material change in disadvantaged ownership and control has occurred since its application was submitted.

(ii) Joint Ventures under the Price Evaluation Adjustment for Small Disadvantaged Business Concerns. The offeror represents, as part of
its offer, that it is a joint venture that complies with the requirements in 13 CFR 124.1002{f) and that the representation in paragraph (c)(10)(i) of this provision is accurate for the small disadvantaged business concern that is participating in the joint venture. [The

offeror shall enter the name of the small disadvantaged business concern that is participating in the joint venture: ------.]
(11) HUBZone small business concern. [Complete only if the offeror represented itself as a small business concern in paragraph (cHI) of this provlsion.] The offeror represents, as part of its offer, that--

41

PC-11-P-AB07

(i) It U is, [_] is not a HUBZone small business concern listed, on the date of this representation, on the List of Qualified HUBZone Small Business Concerns maintained by the Small Business Administration, and no material changes in ownership and control, principal office, or HUBZone employee percentage have occurred since it was certified in accordance with 13 CFR part 126; and (ii) It U is, U is not a HUBZone joint venture that complies with the requirements of 13 CFR part 126, and the representation in paragraph (c)(11)(i) of this provision is accurate for each HUBZone small business concern participating in the HUBZone ioint venture. [The offeror shall enter the names of each of the HUBZone small business concerns participating in the HUBZone joint venture: ____ .J Each HUBZone small business concern participating in the HUBZone joint venture shall submit a separate signed copy of the HUBZone representation. (d) Representations required to implement provisions of Executive Order 11246--

(1) Previous contracts and compliance. The offeror represents that-(i) It U has, U has not, participated in a previous contract or subcontract subject to the Equal Opportunity clause of this solicitation; and (ii) It (2) Affirmative

U has, U has

not, filed all required compliance reports.

Action Compliance. The offeror represents that--

(i) It U has developed and has on file, [_] has not developed and does not have on file, at each establishment, affirmative action programs required by rules and regulations of the Secretary of Labor (41 CFR parts 60-1 and 60-2). or

(ii) It [_] has not previously had contracts subject to the written
affirmative action programs requirement of the rules and regulations of the Secretary of labor. (e) Certification Regarding Payments to Influence Federal Transactions (31 U.S.c. 1352). (Applies only ifthe contract is expected to exceed $150,000.) By submission of its offer, the offeror certifies to the best of its knowledge and belief that no Federal appropriated funds

42

PC-11-P-AB07

have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or an employee of a Member of Congress on his or her behalf in connection with the award of any resultant contract. If any registrants under the lobbying Disclosure Act of 1995 have made a lobbying contact on behalf of the offeror with respect to this contract, the offeror shall complete and submit, with its offer, OMB Standard Form lLl, Disclosure of Lobbying Activities, to provide the name of the registrants. The offeror need not report regularly employed officers or employees of the offeror to whom payments of reasonable compensation were made. (f) Buy American Act Certificate. (Applies only if the clause at Federal Acquisition (FAR) 52.225~1, Buy American Act - Supplies, is included in this solicitation.) Regulation

(1) The offeror certifies that each end product, except those listed in paragraph (f)(2) of this provision, is a domestic end product and that for other than COTS items, the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The offeror shan llst as foreign end products those end products manufactured in the United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of "domestic end product." The terms "commercially available off-the-shelf (COTS) item," "component," "domestic end product," "end product," "foreign end product," and "United States" are defined in the clause of this solicitation entitled "Buy American Act-Supplies." (2) Foreign End Products:

[List as necessary] (3) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25.

43

PC-11-P-AB07

(g)
(1) Buy American Act -- Free Trade Agreements -- Israeli Trade Act Certificate. (Applies only if the clause at FAR 52.225-3, Buy American Act -- Free Trade Agreements --Israeli Trade Act, is included in this solicitation.) (i) The offeror certifies that each end product, except those listed in paragraph (g)(l)(ii) or (g)(l)(iii) of this provision, is a domestic end product and that for other than COTS items/ the offeror has considered components of unknown origin to have been mined, produced, or manufactured outside the United States. The terms "Bahrainian, Moroccan, Omani, or Peruvian end product," "commercially available off-the-shelf (COTS) item," "component," "domestic end product," "end product," "foreign end product," "Free Trade Agreement country," "Free Trade Agreement country end product," "Israeli end product," and 'United States' are defined in the clause of this solicitation entitled "Buy American Act-Free Agreements--Israeli Trade Act." Trade

(ii) The offeror certifies that the following supplies are Free Trade Agreement country end products (other than Bahrainian, Moroccan, Omani, or Peruvian end products) or Israeli end products as defined in the clause of this solicitation entitled "Buy American Act-Free Trade Agreements-Israeli Trade Act": Free Trade Agreement Country End Products (Other than Bahrainian or Moroccan End Products) or Israeli End Products:

[List as necessary}

(iii) The offeror shall list those supplies that are foreign end products
(other than those listed in paragraph (g)(l)(ii) or this provision) as defined in the clause of this solicitation entitled "Buy American ActFree Trade Agreements-Israeli Trade Act." The offeror shall list as

44

PC-11-P-AB07

other foreign end products those end products manufactured

in the

United States that do not qualify as domestic end products, i.e., an end product that is not a COTS item and does not meet the component test in paragraph (2) of the definition of "domestic end product." Other Foreign End Products:

[List as necessary] (iv) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25. (2) Buy American Act-Free Trade Agreements-israeli Trade Act Certificate, Alternate I. If Alternate I to the clause at FAR 52.225-3 is induded in this solicitation, substitute the following paragraph (g)(l)(ii) for paragraph (g)(1)(ii) of the basic provision: (g)(l)(ii) The offeror certifies that the following supplies are Canadian end products as defined in the clause of this solicitation entitled "Buy American Act-Free Trade Agreements-Israeli Trade Act": Canadian End Products: Line Item No.:

[List as necessary] (3) Buy American Act-Free Trade Agreements-Israeli Trade Act Certificate, Alternate II. If Alternate II to the clause at FAR 52.225-3 is included in this solicitation, substitute the following paragraph (g)(l}(ii) for paragraph (g)(1){H) of the basic provision:

45

PC~11-P-AB07

(g)(l){ii) The offeror certifies that the following supplies are Canadian end products or Israeli end products as defined in the clause of this solicitation entitled "Buy American Act--Free Trade Agreements-Israeli Trade Act";
Canadian or Israeli End Products: !Iune Item No.: 11.=········='-'-···· ~ ~~~~I
=-

lco~nt~~fOrigi~:

.

:[:.::=::=============[~. . ~_L
rUst as necessary]

~~~~~~~~~l

(4) Trade Agreements Certificate. (Applies only if the clause at FAR 52.225-5, Trade Agreements, is included in this solicitation.) 0) The offeror certifies that each end product, except those listed in paragraph (g)(4)Oi) of this provision. is a U.S.-made or designated country end product as defined in the clause of this solicitation entitled "Trade Agreements." (ii) The offeror shall list as other end products those end products that are not U.S.-made or designated country end products. Other End Products Line Item No.: _lcountr~o~origin:
:Lr--··-"'--·

~~~~~~--~~~~~~~~==
.----"-----'-"-=-~~___;_;.;;_;.~~="_'=""_:...:.:.:__

__ ...
""-...----".---...._,. -I

"""--~=",,---==~--,,------,,,-,------.

r---======~==~===---==~=-rL--=----·~===---====~====~-=······-=--~---'1
.:L ..
lUst as necessary] (iii) The Government will evaluate offers in accordance with the policies and procedures of FAR Part 25. For line items covered by the WTO GPA, the Government will evaluate offers of U.S.-made or designated country end products without regard to the restrictions

46

PC-11-P-AB07

of the Buy American Act. The Government will consider for award only offers of U.S.-made or designated country end products unless the Contracting Officer determines that there are no offers for such products or that the offers for such products are insufficient to fulfill the requirements of the solicitation.

(h) Certification Regarding Responsibility Matters (Executive Order 12689). (Applies only if the contract value is expected to exceed the simplified acquisition threshold.) The offeror certifies, to the best of its knowledge and belief, that the offeror and/or any of its principals--

{1} L1 Are,
debarment, agency;

Ll

are not presently debarred, suspended, proposed for or declared ineligible for the award of contracts by any Federal

(2) U Have, U have not, within a three-year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a Federal, state or local government contract or subcontract; violation of Federal or state antitrust statutes relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, violating Federal criminal tax laws, or receiving stolen property; and (3) LI Are, Ll are not presently indicted for, or otherwise criminally or civilly charged by a Government entity with, commission of any of these offenses enumerated in paragraph (h}(2) of this clause; and

(4) U Have, U have not, within a three-year period preceding this offer, been notified of any delinquent Federal taxes in an amount that exceeds

$3,000 for which the liability remains unsatisfied.
([) Taxes are considered delinquent apply: (A) The tax Nobility is finally determined. The liability is finally determined if it has been assessed. A liability is not finally determined if there is a pending administrative or judicial challenge. In the case of a judicial challenge to the liability, the liability is not finally determined until all judicial appeal rights have been exhausted. if both of the following criteria

47

PC-11-P-AB07

(B) The taxpayer is delinquent in making payment. A taxpayer is delinquent if the taxpayer has failed to pay the tax liability when full payment was due and required. A taxpayer is not delinquent in cases where enforced collection action is precluded. (ii) Examples. (A) The taxpayer has received a statutory notice of deficiency, under I.R.C. §6212, which entitles the taxpayer to seek Tax Court review of a proposed tax deficiency. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek Tax Court review, this will not be a final tax liability until the taxpayer has exercised all judicial appear rights. (8) The IRS has filed a notice of Federal tax lien with respect to an assessed tax liability, and the taxpayer has been issued a notice under I.R.C. §6320 entitling the taxpayer to request a hearing with the IRSOffice of Appeals Contesting the lien filing, and to further appeal to the Tax Court if the IRS determines to sustain the lien filing. In the course of the hearing, the taxpayer is entitled to contest the underlying tax liability because the taxpayer has had no prior opportunity to contest the liability. This is not a delinquent tax because it is not a final tax liability. Should the taxpayer seek tax court review, this will not be a final tax liability until the taxpayer has exercised all judicial appeal rights. (C) The taxpayer has entered into an installment agreement pursuant to I.R.C. §6159. The taxpayer is making timely payments and is in full compliance with the agreement terms. The taxpayer is not delinquent because the taxpayer is not currently required to make full payment. (D) The taxpayer has filed for bankruptcy protection. The taxpayer is not delinquent because enforced collection action is stayed under 11 U.S.c. §362 (the Bankruptcy Code).

48

PC-11-P-AB07

(i) Certification

Regarding Knowledge of Child Labor for Listed End Products (Executive Order

13126). [The Contracting Officer must list in paragraph (i)(l) any end products being acquired under this solicitation that are included in the List of Products Requiring Contractor Certification as to Forced or Indentured Child Labor, unless excluded at 22.1503(b}.] (1) Listed End Product !iIListedEndProdu~:

!l:.=. .=..:..:':... =::::==::::: ...•==..: = ·.

..

I!tisted c~untri~Sof

~ri~~n: ..

J;:c-::."'~"---'----'---'----'..-~~---'===------'----'-""'----;

'l

llr--:~---'--"-"'-~~--'-'--'-~~---'-'-'-~itr:....

.Jj

=====.~..... ;.;;;;;,;; .... = ... ·~=--'-;I

(2) Certification. [If the Contracting Officer has identified end products and countries of origin in paragraph (1)(1) of this provision, then the offeror must certify to either (i)(2)(i) or (i)(2)(ii) by checking the appropriate block.] [_] (i) The offeror will not supply any end product listed in paragraph (i)(1) of this provision that was mined, produced, or manufactured in the corresponding country as listed for that product.

U (ii) The offeror may supply an end product listed in paragraph (i)(l) of this provision that was mined, produced, or manufactured the corresponding country as listed for that product. The offeror

in

certifies that is has made a good faith effort to determine whether forced or indentured child labor was used to mine, produce, or manufacture any such end product furnished under this contract. On the basis of those efforts, the offeror certifies that it is not aware of any such use of child labor. (j) Place of manufacture. (Does not apply unless the solicitation is predominantly for the acquisition of manufactured end products.) For statistical purposes only, the offeror shall indicate whether the place of manufacture of the end products it expects to provide in response to this solicitation is predominantly(1) U In the United States (Check this box ifthe total anticipated price of offered end products manufactured in the United States exceeds the total anticipated price of offered end products manufactured outside the United States); or

49

PC-11-P-AB07

(2)

U Outside

the United States.

(k) Certificates regarding exemptions from the application of the Service Contract Act. (Certification by the offeror as to its compliance with respect to the contract also constitutes its certification as to compliance by its subcontractor if it subcontracts out the exempt services.) [The contracting officer is to check a box to indicate if paragraph (k)(l) or (k}(2) applies.] (1) [_] Maintenance, calibration, or repair of certain equipment as described in FAR 22.1003-4(c)(1). The offeror LJ does U does not certify that(i) The items of equipment to be serviced under this contract are used regularly for other than Governmental purposes and are sold or traded by the offeror (or subcontractor in the case of an exempt subcontract) in substantial quantities to the general public in the course of normal business operations; (ii) The services will be furnished at prices which are, or are based on, established catalog or market prices (see FAR 22.1003-4(c)(2)(ii)) for the maintenance, calibration, or repair of such equipment; and

(iii) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract will be the same as that used for these employees and equivalent employees servicing the same equipment of commercial customers. (2) LJ Certain services as described in FAR 22.1003-4(d)(1). does Ll does not certify thatThe offeror [_]

(i) The services under the contract are offered and sold regularly to non-Governmental customers, and are provided by the offeror (or subcontractor in the case of an exempt subcontract) to the general public in substantial quantities in the course of normal business operations;

(ii) The contract services will be furnished at prices that are, or are
based on, established catalog or market prices (see FAR 22.10034(d)(2)(iii)); (iii) Each service employee who will perform the services under the contract will spend only a small portion of his or her time (a monthly

50

PC-11-P-A807

average of less than 20 percent of the available hours on an annualized basis, or less than 20 percent of available hours during the contract period if the contract period is less than a month) servicing the Government contract; and (iv) The compensation (wage and fringe benefits) plan for all service employees performing work under the contract is the same as that used for these employees and equivalent employees servicing commercial customers. (3) If paragraph (k)(l) or (k)(2) of this clause applies(i) If the offeror does not certify to the conditions in paragraph (k)(l) or (k)(2) and the Contracting Officer did not attach a Service Contract Act wage determination to the solicitation, the offeror shall notify the Contracting Officer as soon as possible; and (ii) The Contracting Officer may not make an award to the offeror if the offeror fails to execute the certification in paragraph (k)(l) or (k)(2) of this clause or to contact the Contracting Officer as required in paragraph (k)(3)(i) of this clause.

(I) Taxpayer identification

number (TIN) (26 U.S.c. 6109, 31 U.s.C. 7701). (Not applicable if the offeror is required to provide this information to a central contractor registration database to be eligible for award.) (1) All offerors must submit the information required in paragraphs (1)(3) through (I)(S) of this provision to comply with debt collection requirements of 31 U.s.c. nOl(c) and 3325(d), reporting requirements of 26 U.S.C. 6041, 6041A, and 6050M, and implementing regulations issued by the Internal Revenue Service (IRS). (2) The TIN may be used by the government to collect and report on any delinquent amounts arising out of the offeror's relationship with the Government (31 U.S.C. 7701(c)(3}). If the resulting contract is subject to the payment reporting requirements described in FAR 4.904, the TIN provided hereunder maybe matched with IRS records to verify the accuracy of the offeror's TIN.] {3} Taxpayer Identification Number (TIN).

51

PC-11-P-AB07

L1 TIN: U TIN
has been applied for.

_

[_] TIN is not required because: is a nonresident alien, foreign corporation, or foreign partnership that does not have income effectively connected with the conduct of a trade or business in the United States and does not have an office or place of business or a fiscal paying agent in the United States;

L1 Offeror

L1 Offeror U Offeror

is an agency or instrumentality

of a foreign government; of the Federal

is an agency or instrumentality Government; (4) Type of organization.

L1 Sole proprietorship;
U Partnership;

U Corporate

entity (not tax-exempt);

[J Corporate entity (tax-exempt);

[J Government entity (Federal, State. or local);

U U

Foreign government;

[J International organization per 26 CFR 1.6049-4;
Other _

(5) Common parent.

U Offeror
U Name
Name TIN

is not owned or controlled and TIN of common parent:

by a common parent:

_ _

52

PC-11-P-AB07

(m) Restricted business operations in Sudan. By submission of its offer, the offeror certifies that the offeror does not conduct any restricted business operations in Sudan. (n) Prohibition on Contracting with Inverted Domestic Corporations. (1) Relation to Internal Revenue Code. A foreign entity that is treated as an inverted domestic corporation for purposes of the Internal Revenue Code at 26 U.S.c. 7874 (or would be except that the inversion transactions were completed on or before March 4, 2003), is also an inverted domestic corporation for purposes of 6 U.S.c. 395 and for this sollcltatton provision {see FAR 9.108). (2) Representation. By submission of its offer, the offeror represents that it is not an inverted domestic corporation and is not a subsidiary of one. (0) Sanctioned activities relating to Iran. {1} Unless a waiver is granted or an exception applies as provided in paragraph (0)(2) of this provision, by submission of its offer, the offeror certifies that the offeror, or any person owned or controlled by the offeror, does not engage in any activities for which sanctions may be imposed under section 5 of the Iran Sanctions Act of 1996. (2) The certification not apply if-requirement of paragraph (0)(1) of this provision does

(i) This solicitation includes a trade agreements certification 52.212-3(g) or a comparable agency provision); and

(e.g.,

(ii) The offeror has certified that all the offered products to be
supplied are designated country end products. (End of Provision) Alternate I (Apr 2011). As prescribed in 12.301(b)(2), add the following the basic provision: (12) (Complete if the offeror has represented paragraph (c}(4) or (c)(lO) of this provislon.) paragraph (c)(12) to

itself as disadvantaged

in

[The offeror shall check the category in which its ownership faUs]:
Black American.

53

PC-11-P-AB07

_

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 or 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). _ Individual/concern, other than one of the preceding. paragraph (c)(10)(iii)

Alternate /I (Apr 2011). As prescribed in 12.301(b)(2), add the following to the basic provision:

(iii) Address. The offeror represents that its address Uis, U is not in a region for which a small disadvantaged business procurement mechanism is authorized and its address has not changed since its certification as a small disadvantaged business concern or submission of its application for certification. The list of authorized small disadvantaged business procurement mechanisms and regions is posted at http://www.arnet.gov/References/sdbadjustments.htm. The offeror shall use the list in effect on the date of this solicitation. "Address," as used in this provision, means the address of the offeror as listed on the Small Business Administration's register of small disadvantaged business concerns or the address on the completed application that the concern has submitted to the Small Business Administration or a Private Certifier in accordance with 13 CFR part 124, subpart B. For joint ventures, "address" refers to the address of the small disadvantaged business concern that is participating in the joint venture.

End of Section K

54

PC-11-P-AB07

SECTION L- INSTRUCTIONS, CONDITIONS AND NOTICES
52.212-1 -- Instructions to Offerors -- Commercial Items (Jun 2008) This section provides general guidance for preparing proposals as well as specific instructions on the format and content of the proposal. The offeror's proposal must include all data and information stated herein and in accordance with these instructions. Nonconformance with the instructions provided may result in an unfavorable submission/proposal evaluation. All claimed technical and past performance capabilities to meet the requirements shall be realistic and are subject to verification by the Government. The offer shall be compliant with the requirements as stated in the Statement of Work. The government intends to award a contract without discussions with respective offerors. Therefore, the offeror's initial proposal should contain the offeror's best terms from a cost or price and technical standpoint. The Government reserves the right to conduct discussions if the Contracting Officer later determines them to be necessary. Ifthe Government·awards without discussions, the offerors may be given the opportunity to clarify certain aspects of proposals (e.g., the relevance of an offeror's past performance information and adverse past performance information to which the offeror has not previously had an opportunity to respond) or to resolve minor clerical errors. The proposal shall not simply rephrase or restate the Government's requirements, but rather shall provide convincing rationale to address how the offeror intends to meet these requirements (e.g. by, technical qualifications ). Offerors shall assume that the government has no prior knowledge of their experience and will base its evaluation on the information presented in the offeror's proposal. The offeror'S proposal must convey to the Government that the offeror is capable; possesses sufficient technical expertise and experience; possesses sufficient resources; and is able to plan, organize, and use those resources in a coordinated and timely fashion such that technical requirements will be achieved and costs will be controlled. To assure timely and equitable evaluation of proposals, offerors must follow the instructions contained herein. Offerors are required to meet all solicitation requirements, including terms and conditions, representations and certifications, and technical requirements, in addition to those identified as evaluation factors. Failure to meet a requirement may result in an offer being ineligible for award. Offerors must clearly identify any exception to the solicitation terms and conditions and provide complete accompanying rationale. The Peace Corps will evaluate only complete proposals. A complete proposal shall state that offers are valid for a period of at least 90 days following submission.

55

PC-11-P-A807

All proposals submitted

in response to this RFPshall become the property of the Peace Corps. of

Peace Corps assumes no financial liability for costs incurred by Offerors in the preparation proposals.

Proposals shall be submitted on 8 Y2x ll-inch paper, double-spaced divided into the three (3) volumes (Technical, Past Performance and Price). Except for reproduced sections of the solicitation document, text shall be no smaller than 12 point, except for tables and graphs. Margins on all four sides of each sheet will be at least one inch. All pages shall be printed on one side only. Special consideration will not be given for colors, pictures or unnecessary graphics. Audio and video recordings, or any other electronic media, to include responses to this solicitation will not be accepted. E-mail or any electronic response will not be considered for award.

All proposals shall be identified with the solicitation

number on the outside of the mailing container and sent via UPS, Federal Express, or Courier. Please note the Government is not responsible for shipping and proposal costs. DO NOT SEND VIA UNITED STATES POSTAL SERVICEMAl L. Offerors are instructed Specialist below: Peace Corps Office of Acquisitions and Contract Management Attn: Ms. Angela Bailey 1111 20th St, NW. Washington, DC. 20526 Proposals are due by 12:00 PM. EST.on June 7,2011. to submit three (3) proposal copies and 1 CD-ROM to the Contract

Provide Offeror Representations

and Certifications

in accordance with Section K.

Offerors should address all questions, concerns, or requests for clarification in writing via email to Angela Bailey at abailey@peacecorps.gov by 12:00 PM. EST.on May 31, 2011. The Peace Corps will post an amendment to this solicitation answering questions. We will not post duplicate questions.

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Proposal Requirements: 1. Technical Proposal: The Technical Capability Volume will be evaluated in accordance with Addendum to FAR 52.212-2, Evaluation Criteria and Basis for Award. Offerors will demonstrate how they will accomplish the requirements of the Statement of Work. This information shall be detailed, specific and complete. Legibility, clarity, and coherence are very important. The Offeror shall provide narrative responses to each of the following technical requirements: A) Personnel Experience • Provide, name, experience, and credentials of personnel performing the work, including primary dentist, backup, and office/clerical staff. Provide detailed resumes.

8) Applicant • •

Screening as described in this RFP.

Explain your experience with dental screening

Provide plan for reviewing applicants within 2 working days of the retrieval of the records and returning results to Peace Corps.

C) Field Consultation • • Explain your experience with field consultation as described in this RFP.

Provide plan for reviewing cases that are sent from the field that require consultation with OMS staff.

0) Post Service Evaluation • Explain your experience with reviewing workers compensation described in this RFP Provide plan for review of cases and reporting results. claims as

2.

Past Performance Proposal: The Past Performance Volume will be evaluated in accordance with Addendum to

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PC-11-P-AB07

FAR 52.212-2, Evaluation Criteria and Basis for Award. In conducting the past performance assessment, the Government will use data provided by offerors and may use data obtained from other sources. Offerors are reminded that while the Government may elect to consider data obtained by other sources, the burden of providing thorough and complete past performance information rests with the offerors. The offeror shall provide three (3) past performance references and describing directly related or similar performance for each within the last three (3) years. The offeror shall provide the following performance: information regarding its past

A. Contract Number(s) and type of contract; B. Procuring Agency and name of reference point(s) of contact and telephone number(s) at the entity for which the contract was performed; C. Dollar value of the Contract; D. Period of Performance; E. Detailed description of the item(s) supplied and/or services rendered; F. The number, type, frequency, duration and impact of any quality, delivery or cost problems in performing the contract, the corrective action taken, if any, and the effectiveness of the corrective action. Offerors must either provide the above information or affirmatively state that it possesses no relevant directly related or similar past performance. In evaluating past performance, the Government may contact some of the references provided by the offeror and other sources of information.

3.

Price Proposal: All pricing information a. b. c.

shall be addressed ONLY in the Price proposal volume.

Provide a fully completed Schedule of Prices in accordance with Section B for the Base and all Option Year Periods; Provide a signed SF 1449 and signed SF 30/ Amendments Provide a completed Representations (if applicable); and

& Certifications (Section K).

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PC-11-P-ABD7

All signatures shall be in accordance with FAR 4.102. The proposal must be signed by an Offeror who is authorized to negotiate for and contractually bind the Offeror.

SECTION M- EVALUATION

FACTORS FOR AWARD

52.212-2 -- Evaluation -- Commercial Items (Jan 1999)
(a) The Government will award a contract resulting from this solicitation to the responsible offeror whose offer conforming to the solicitation will be most advantageous to the Government, price and other factors considered. The following evaluation factors are listed below in descending order of importance where Technical and Past Performance Factors when combined are significantly more important than Price:

1. Technical capability to meet the mandatory requirements
in Section C.

as stated

1.1 Quality of Personnel/Experience
• • • Applicant Screening Field Consultation Post Service Evaluation

2. Past Performance 3. PRICE
The Price Proposal will be evaluated separately and overall prices are considered less important than the strengths of the technical proposal and past performance combined. However, where proposals are considered essentially equal, price may be the determining factor in selecting a Contractor for award. The overall

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standard for judging price proposals will be whether the price proposal presents the best value to the government for the technical approach proposed. The Government reserves the right to make an award to other than the lowest priced Offeror if the Contracting Officer determines that to do so would be most advantageous to the Government.

52.217-5 -- Evaluation of Options (JuI1990)
Except when it is determined in accordance with FAR 17.206(b) not to be in the Government's best interests, the Government will evaluate offers for award purposes by adding the total price for all options to the total price for the basic requirement. Evaluation of options will not obligate the Government to exercise the option(s). EVALUATION RATINGS

Technical and Past Performance proposals will be evaluated based on the following adjectival ratings:
OUTSTANDING

Proposal satisfies all of the Government's requirements and indicates thorough and comprehensive understanding of the requirement and offers numerous significant strengths, which are not offset by weaknesses, with an overalilow degree of risk in meeting the Government's requirement.

GOOD

Proposal satisfies all of the Government's requirements and indicates a thorough understanding of the requirement and offers some significant strengths or numerous minor strengths, which are not offset by weaknesses, with an overall low to moderate degree of risk in meeting the Government's requirement. Proposal satisfies all of the Government's requirements and indicates an adequate understanding of the requirement, with an overall moderate to high degree of risk in meeting the Government's requirement. Proposal satisfies all of the Government's requirement but indicates

ACCEPTABLE

MARGINAL

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PC-11-P-AB07

a superficial or vague understanding

of the requirement,

with an

overall high degree of risk in meeting the Government's requirement.
UNACCEPTABLE

The proposal contains major error(s), omission(s) or deficiency pes) and indicates a lack of understanding of the requirement and cannot be expected to meet the requirement or involves a very high risk.

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