EX-10.4 3 pdm291d.txt CONTRACT DEPARTMENT OF VETERANS AFFAIRS Medical Center 508 Fulton Street Durham NC 27705 January 23, 2002 In Reply Refer To: 558/90C National Research Corporation Attn: Patrick E. Beans 1245 Q. Street Lincoln, NE 68508 Dear Mr. Bean: Acceptance is made of your offer submitted in response to our RFQ 558-Q4l-02 to furnish Veteran Satisfaction Surveys for the Performance Analysis Center for Excellence (PACE), located at 615 Davis Drive, Suite 800, Morrisville, NC, under the MOBIS Contract No. GS-1OF-0332L. The period of the contract is established for January 23, 2002 through September 30, 2002 in the estimated annual amount of $4,665,882.00. Purchase Order Number 558-HT1002 has been assigned and must appear on all invoices and future correspondence. An executed copy of the contract is enclosed for your files. In accordance with VAAR Clause 852.270-1, PACE Staff members have been delegated Contracting Officer's Technical Representatives on this contract. All work performed under this contract must be coordinated through the representatives. A copy of the memo of delegation is enclosed. Payment will be made monthly in arrears upon submission of your properly prepared invoice to the Resource Support Service (04), VA Medical Center (558), 1970 Roanoke Blvd., Salem, VA 24153. The contract number must be reflected on your invoice. If there are any questions, please feel free to contact the undersigned at (919) 286-6915. Sincerely, BERMA K. NORRIS Contracting Officer Enclosures: Purchase Order No. 558-HT1002 Delegation of COTR 1
==================================================================================================================================== SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE 1 OF 36 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24 & 30 558-02-2-8888-0944 ------------------------------------------------------------------------------------------------------------------------------------ 2. CONTRACT NO. 3. AWARD/EFFECTIVE 4. ORDER NUMBER 5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE GS-10F-0332L DATE 1/23/02 558-HT1002 558-Q41-02 10/9/2001 ------------------------------------------------------------------------------------------------------------------------------------ 7. FOR SOLICITATION a. NAME b. TELEPHONE NUMBER (No 8. OFFER DUE DATE/ INFORMATION CALL: Berma Norris Collect Calls) 10/24/01; 4:30 pm LOCAL 919/286-6915 ------------------------------------------------------------------------------------------------------------------------------------ 9. ISSUED BY CODE 558/90C 10. THIS ACQUISITION IS 11. DELIVERY FOR FOB 12. DISCOUNT TERMS DESTINATION UNLESS |X| UNRESTRICTED BLOCK IS MARKED |_| SET ASIDE % FOR |_| SEE SCHEDULE Department of Veterans Affairs |_| SMALL BUSINESS VA Medical Center |_| SMALL DISADV. BUSINESS Acquisition Materiel Management (90C) |_| 8(A) 508 Fulton Street Durham, NC 27705 NAICS Attn: Berma Norris SIC. 541613 SIZE STANDARD: $5.0 MILLION ------------------------------------------------------------------------------------------------------------------------------------ |_|13A. THIS CONTRACT IS A RATED ORDER UNDER DPAS (15 CFR 700) N/A ------------------------------------------------------------------------------------------------------------------------------------ 13B. RATING N/A ------------------------------------------------------------------------------------------------------------------------------------ 14. METHOD OF SOLICITATION |X| RFQ |_| IFB |_| RFP ------------------------------------------------------------------------------------------------------------------------------------ 15. DELIVER TO CODE 16. ADMINISTERED BY CODE Same as Block 9 Same as Block 9 ------------------------------------------------------------------------------------------------------------------------------------ CODE 1TFT6 FACILITY 18A. PAYMENT WILL BE MADE BY CODE CODE National Research Corporation RESOURCES SUPPORT SERVICE (04) 1245 Q. Street VA Medical Center (558) Lincoln, NE 68508 1970 Roanoke Blvd. Salem, VA 24153 Duns No. 05-085-7788 Telephone No. 800-388-4264 fax 402-475-9061 ------------------------------------------------------------------------------------------------------------------------------------ |_| 18B.SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18A UNLESS BLOCK BELOW IS CHECKED 17B.CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH |_| SEE ADDENDUM ADDRESS IN OFFER ------------------------------------------------------------------------------------------------------------------------------------ 19 20 21 22 23 24 ITEM NO. SCHEDULE OF SUPPLIES/SERVICE QUANTITY UNIT UNIT PRICE AMOUNT ------------------------------------------------------------------------------------------------------------------------------------ 1. Furnish Veteran Satisfaction Surveys in accordance Attached with the attached scope of work for the Performance Analysis Center for Excellence (PACE) located at 615 Davis Drive, Suite 800, Morrisville, NC, in accordance with MOBIS - Schedule 874-3 Survey Services. AS DESCRIBED HEREIN: (ATTACH ADDITIONAL SHEETS AS NECESSARY) ------------------------------------------------------------------------------------------------------------------------------------ 25. ACCOUNTING AND APPROPRIATION DATA 26. TOTAL AMOUNT AWARD (FOR GOVT. USE ONLY) 36X4537B3 BOC 2529 Cost Center 615300 HT1002 Est. $4,665,882.00 ------------------------------------------------------------------------------------------------------------------------------------ |X| 27A.SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 ADDENDA |X| ARE |_| ARE NOT ATTACHED. AND FAR 52.212-5 ARE ATTACHED. |_| 27B.CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. ADDENDA |_| ARE |_| ARE NOT ATTACHED. FAR 52.212-5 IS ATTACHED. ------------------------------------------------------------------------------------------------------------------------------------ 28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN ___0____ COPIES 29. AWARD OF CONTRACT: REFERENCE __your__ OFFER TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER ALL ITEMS SET |X| YOUR OFFER ON SOLICITATION (BLOCK 5), |X| FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL SHEETS SUBJECT TO INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET THE TERMS AND CONDITIONS SPECIFIED HEREIN. FORTH HEREIN, IS ACCEPTED AS TO ITEMS: MARKED "A" DATED 10/23/01 ------------------------------------------------------------------------------------------------------------------------------------ 30A. SIGNATURE OF OFFEROR/CONTRACTOR 31A. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) ------------------------------------------------------------------------------------------------------------------------------------ 30B. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30C DATE SIGNED 31B. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31C. DATE SIGNED Patrick E. Beans, CFO 10/23/01 BERMA K. NORRIS ------------------------------------------------------------------------------------------------------------------------------------ 32A. QUANTITY IN COLUMN 21 HAS BEEN 33. SHIP NUMBER 34. VOUCHER NUMBER 35. AMOUNT VERIFIED CORRECT FOR |_| RECEIVED |_| INSPECTED |_| ACCEPTED AS CONFORMS TO THE ----------------- CONTRACT, EXCEPT AS NOTED PARTIAL FINAL ------------------------------------------------------------------------------------------------------------------------------------ 32B. SIGNATURE OF AUTHORIZED GOVT. REPRESENTATIVE 32C. DATE 36. PAYMENT 37. CHECK NUMBER __ COMPLETE __ PARTIAL __ FINAL ------------------------------------------------------------------------------------------------------------------------------------ 41A. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT 38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY ------------------------------------------------------------------------------------------------------------------------------------ 42A. RECEIVED BY (PRINT) ------------------------------------------------------------------------------------------------------------------------------------ 41B. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41C. DATE 42B. RECEIVED AT (LOCATION) ------------------------------------------------------------------------------------------------------------------------------------ 42C. DATE REC'D 42D. TOTAL CONTAINERS (YY/MM/DD) ------------------------------------------------------------------------------------------------------------------------------------
2 RFQ 558-Q41-02 CONTINUATION BLOCK 2.1 CONTRACT ADMINISTRATION DATA (continuation from Standard Form 1449, block 18A.) 1. Contract Administration: All contract administration matters will be handled by the following individuals: a. CONTRACTOR: National Research Corporation 1245 Q. Street Lincoln, NE 68508 b. GOVERNMENT: Contracting Officer (90C) Berma Norris Dept. of Veterans Affairs Medical Center 508 Fulton Street Durham NC 27705-3875 2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with: [X] 52.232-34, Payment by Electronic Funds Transfer - Other than Central Contractor Registration, or mailed to the following address: ------------------------------------------------ --------------------------------------------- --------------------------------------------- 3. INVOICES: Invoices shall be submitted in arrears: a. Quarterly [ ] b. Semi-Annually [ ] c. Other [X] (please specify) Monthly ------- 4. GOVERNMENT INVOICE ADDRESS: All invoices from the contractor shall be mailed to the following address: Fiscal Officer (04) Department of Veterans Affairs Medical Center 508 Fulton Street Durham, NC 27705 OFFERORS MUST COMPLETE AND RETURN ALL INFORMATION DESIGNATED IN 52.212-1, INSTRUCTIONS TO OFFERORS - COMMERCIAL ITEMS, PARAGRAPH b, PRIOR TO THE TIME SPECIFIED IN BLOCK 8 OF SF 1449 IN ORDER TO BE CONSIDERED FOR AWARD. ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows: 3 Price/Cost Proposal - VHA RFQ NRC Alternate Approach 4 Price/Cost Proposal - VHA RFQ NRC Alternate Approach Base Year - September 2002 -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 1. Recently Discharged Inpatient Survey Semi-Annually (* estimated patients) 2 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 2. Ambulatory Care Survey General Primary Care Visits (Quarterly) (* estimated patients) 4 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 3. Ambulatory Care Survey Persian Gulf Era Survey (Deployed and Non-Deployed) Annually 1 Surveys * * (* estimated patients) 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 5 -------------------------------------------------------------------------------- 4. Ambulatory Care Spinal Cord Patient Survey Annually (* estimated patients) 1 Surveys * * 16 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 5. Home Based Primary Care Survey Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 6. Prosthetics and Sensory Aids Patient Survey (* estimated patients) 1 Surveys * * 10 pages approx. (Every other year) Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 7. Diabetic Foot Care (DQIP) Annually (* estimated patients) 1 Surveys * * 20 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 6 The Government may exercise the option to renew this contract for four (4) additional years in accordance with Clause 52.217-9. If the option is exercised, written notice will be provided. SUPPLIES OR SERVICES AND PRICE/COST OPTION YEAR I: Contractor to provide all labor, equipment, materials and supervision to process Patient Surveys as listed herein for the Department of Veterans Affairs for the period of October 1, 2002 through September 30, 2003. -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 1. Recently Discharged Inpatient Survey Semi-Annually (* estimated patients) 2 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 2. Ambulatory Care Survey General Primary Care Visits (Quarterly) (* estimated patients) 4 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 7 -------------------------------------------------------------------------------- 3. Ambulatory Care Survey Persian Gulf Era Survey (Deployed and Non-Deployed) Annually (*estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 4. Ambulatory Care Spinal Cord Patient Survey Annually (* estimated patients) 1 Surveys * * 16 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 5. Home Based Primary Care Survey Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 6 Diabetic Foot Care (DQIP) Annually (* estimated patients) 1 Surveys * * 20 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 8 SUPPLIES OR SERVICES AND PRICE/COST OPTION YEAR II: Contractor to provide all labor, equipment, materials and supervision to process Patient Surveys as listed herein for the Department of Veterans Affairs for the period of October 1, 2003 through September 30, 2004. -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 1. Recently Discharged Inpatient Survey Semi-Annually (* estimated patients) 2 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 2. Ambulatory Care Survey General Primary Care Visits (Quarterly) (* estimated patients) 4 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 3. Ambulatory Care Survey Persian Gulf Era Survey (Deployed and Non-Deployed) Annually (*estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 9 -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 4. Ambulatory Care Spinal Cord Patient Survey Annually (* estimated patients) 1 Surveys * * 16 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 5. Home Based Primary Care Survey Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 6. Prosthetics and Sensory Aids Patient Survey (* estimated patients) 1 Surveys * * 10 pages approx. (Every other year) Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 7. Diabetic Foot Care (DQIP) Annually (* estimated patients) 1 Surveys * * 20 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 10 SUPPLIES OR SERVICES AND PRICE/COST OPTION YEAR III: Contractor to provide all labor, equipment, materials and supervision to process Patient Surveys as listed herein for the Department of Veterans Affairs for the period of October 1, 2004 through September 30, 2005. -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 1. Recently Discharged Inpatient Survey Semi-Annually (* estimated patients) 2 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 2. Ambulatory Care Survey General Primary Care Visits (Quarterly) (* estimated patients) 4 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 3. Ambulatory Care Survey Persian Gulf Era Survey (Deployed and Non-Deployed) Annually (*estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 11 -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 4. Ambulatory Care Spinal Cord Patient Survey Annually (* estimated patients) 1 Surveys * * 16 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 5. Home Based Primary Care Survey Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 6. Diabetic Foot Care (DQIP) Annually (* estimated patients) 1 Surveys * * 20 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 12 SUPPLIES OR SERVICES AND PRICE/COST OPTION YEAR IV: Contractor to provide all labor, equipment, materials and supervision to process Patient Surveys as listed herein for the Department of Veterans Affairs for the period of October 1, 2005 through September 30, 2006. -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 1. Recently Discharged Inpatient Survey Semi-Annually (* estimated patients) 2 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 2. Ambulatory Care Survey General Primary Care Visits (Quarterly) (* estimated patients) 4 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 3. Ambulatory Care Survey Persian Gulf Era Survey (Deployed and Non-Deployed) Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 13 -------------------------------------------------------------------------------- ITEM TOTAL NO. SURVEY DESCRIPTION QTY UNIT UNIT COST COST -------------------------------------------------------------------------------- 4. Ambulatory Care Spinal Cord Patient Survey Annually (* estimated patients) 1 Surveys * * 16 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 5. Home Based Primary Care Survey Annually (* estimated patients) 1 Surveys * * 12 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 6. Prosthetics and Sensory Aids Patient Survey (* estimated patients) 1 Surveys * * 10 pages approx. (Every other year) Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- 7. Diabetic Foot Care (DQIP) Annually (* estimated patients) 1 Surveys * * 20 pages approx. Set Up Costs * Printing * Distribution Costs * Receipt and Processing Costs * Comment Capture * Reporting * POSTAGE * -------------------------------------------------------------------------------- * Indicates that material has been omitted and confidential treatment has been requested therefor. All such omitted material has been filed separately with the SEC pursuant to Rule 24b-2. 14