Sources Sought: Medical Equipment - Acuity System Charts @ Fort Thompson IHS

Form / Attachment / Pricing Sheet

This document is the "Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form." It is used by offerors to self-certify that they meet the definition of an "Indian Economic Enterprise" as required by the Buy Indian Act. This self-certification is necessary when responding to Sources Sought Notices, Requests for Information (RFIs), or Solicitations that may result in a contract under the Buy Indian Act.

• Eligibility Criteria: The form requires the offeror to confirm they meet the definition of an "Indian Economic Enterprise" throughout the offer submission, contract award, and performance periods.
• Notification Requirement: Offerors must notify the Contracting Officer immediately if they no longer meet eligibility requirements.
• Documentation: Contracting Officers may request documentation of eligibility, and awards may be subject to protest.
• Registration: Successful offerors must be registered with the System of Award Management (SAM).
• Penalties: False or misleading information is subject to legal penalties.
• Representation Section: Includes checkboxes for the offeror to represent whether they meet the definition of an "Indian Economic Enterprise" with "Indian Ownership."
• Information Fields: Requires the Offeror to provide:
  • Name of Federally Recognized Tribal Entity
  • Name of the 51% owner of IEE Firm
  • Business Name
  • DUNS Number
  • Certifying Signature
  • Print Name

This form is critical for any bidder intending to claim status as an "Indian Economic Enterprise" for an opportunity subject to the Buy Indian Act. Bidders must accurately complete and submit this form to demonstrate their eligibility for potential set-aside or sole-source contracts under this authority. Failure to meet the criteria or complete the form correctly could disqualify a bid.

Statement of Work (SOW)

To provide the award of a firm-fixed-price contract for Optometry Equipment for the Fort Thompson Service Unit in Fort Thompson, SD.

The Contractor shall provide specific optometry equipment within 180 days of contract award. Delivery is to the Fort Thompson Service Unit, requiring freight delivery with lift-gate capability between 8:00 AM and 5:00 PM Central Standard Time.

The required equipment includes:

• Acuity System Charts (2)
• Tonometer (1)
• Auto Kerato-Refractometer (1)
• Indirect Ophthalmoscopes (1)
• Manual Phoropter Refractor (1)
• Spot Vision Screener (1)
• Transilluminator (1)
• Ophthalmoscope (1)
• Retinoscope (1)
• Well Handles (3)
• Handheld Tonometer (1)
• Auto Lensmeter (1)

Detailed specifications for each item are provided, covering aspects like screen size, measurement ranges, power supply, connectivity, and specific features.

180 days from the date of issuance.

• Privacy Act: The Contractor must comply with the Privacy Act of 1974 and applicable agency regulations if designing, developing, or operating a system of records on individuals. This includes ensuring employees are aware of rules and potential criminal penalties for violations. Subcontracts must also adhere to these requirements.
• Confidential Information: The Contractor shall not disclose confidential information, including Patient Identifiable PHI/PII and Networking Infrastructure, without advance written notice (at least 45 days) to the Contracting Officer and written consent for publication or dissemination.
• Government Authority: Only the Contracting Officer has the authority to bind the Government regarding this contract. No other employee actions can modify the contract scope or terms.