Office of Small and Disadvantaged Business Utilization hhs 653 Small Business Review Form




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Office of Small and Disadvantaged Business Utilization

HHS 653 - Small Business Review Form
OSDBU Control Number: _______________________________________Date Received: ______________________________


A. Project Information



1. Solicitation Number: ________________________


Acquisition Instrument Proposed/Contract Type:

[ ] Contract No: ___________________________

[ ] Departmental IDIQ No: ___________________

[ ] GSA Schedule No: ______________________

[ ] GWAC Contract No: _____________________
[ ] HHS BPA (Strategic Sourcing):
[ ] Posted/Identified on HHS OPDIV Forecast

[ ] ARRA Funds: TAS No.____________________


2. Acquisition Office and OPDIV:


CO/CS/COTR/PA Name:
Location (Bldg. and Room):

Contact Information (Telephone, Fax and E-mail):






3. Brief description of services or products to be procured:



4. Total Estimated Value (Including Options): $ ________________ Base: $ _________________ Options: $ ________________






5.a. Period of Performance (including Options) or Delivery Date: ___________________________________________________.

5.b. The RFP/RFQ will be posted within ___30 days;___90 days;___6 months after the OSDBU Small Business Specialist review.



B. Project Considerations



6. NAICS Code: __________________________

Dollars: _______________________________

No. of Employees: ______________________


7. [ ] New Requirement [ ] Recompetition [ ] Similar Requirement


Acquisition History:
Previous Contract Number: ______________ Award Date: __________

Total Amount of Contract Award: _______________________________

Contractor Name: ___________________________________________

Contractor Size/Type of Ownership: _____________________________

Previous/NAICS Code/Size Standard: ___________________________

Number of Offers from Small Business: _______

Comments: ________________________________________________

8. Bundling/Consolidation:

[ ] N/A: Below established threshold: FAR 7.104(d)(2)
Yes No

[ ] [ ] Is requirement consolidated?

If yes, attach supporting documentation.
[ ] [ ] Project Officer certified the bundling status.




9. Efforts made to locate sources within last 12 months:


CO SBS

[ ] [ ] Review of Prior or Similar Acquisition

[ ] [ ] Contracting Officer (Comments Attached)

[ ] [ ] Program Office (Comments Attached)

[ ] [ ] Sources Sought Notice (Copy Attached)

[ ] [ ] Market Survey (Copy Attached)

[ ] [ ] Consult HHS Small Business Specialist

[ ] [ ] Central Contractor Registration (CCR)

[ ] [ ] Other: _________________________

10. Acquisition Method(s)


[ ] 8(a) Set-Aside/Competitive/Sole Source (SBA Offering Letter)

[ ] HUBZone Set-Aside/Competitive/Sole Source

[ ] Service-Disabled Veteran-owned (SDVOSB) Set-Aside

[ ] Total Small Business Set-Aside

[ ] Partial Small Business Set-Aside

[ ] Urban Indian Organization (P.L. 94-437) and Buy Indian Act (25 USC 47) – IHS HCA Authorization required.

[ ] JOFOC (Authority): ______________________________

[ ] No Reasonable expectation of obtaining 2 or more SB offers.

[ ] Other (explain): _________________________________




11. Synopsis:


[ ] Yes (FEDBIZOPPS)

[ ] No. Per FAR 5.202 ______

[ ] Other:_________________

12. Other Considerations that apply to the Solicitation:

Yes No Yes No

[ ] [ ] Subcontracting Plan (if no, see instructions) [ ] [ ] SDB Plan

[ ] [ ] Green Contracting Considerations

Other: ____________________________________________________________







C. Project Review & Approval

13. Cognizant Contracting Official:



_ _ ___ ___

Signature Date


14. OSDBU Small Business Specialist:

[ ] Concur [ ] Non-concurrence:
_ __ ______

Signature Date


15. SBA Procurement Center Representative:

[ ] Concur [ ] Non-concurrence:
___ __ __

Signature Date




HHS 653- SMALL BUSINESS REVIEW FORM INSTRUCTIONS

PROJECT INFORMATION (ITEMS 1 – 5)
1. Enter the solicitation number. Indicate acquisition instrument/contract type by checking appropriate box:


In accordance with PL 100-656, each OPDIV is required to post its Forecast Information http://osdbuforecast.hhs.gov/)


In accordance with Presidential Memorandum M-09-10, agencies shall identify procurements which use American Recovery and Reinvestment Act (ARRA) funds. If available, reference a Treasury Account Symbol (TSA).
2. Enter Contracting Officer/Specialist (CO/CS), Contracting Officer Technical Representative (COTR) or Purchasing Agent’s Name, OPDIV, Building, Room, Telephone, Fax and e-mail.
3. Enter the item/service description or project title.
4. Enter the total estimated dollar value of the contract, including all options. If necessary attach information.
5. a. Enter the estimated period of performance, including any option periods, using (mm/dd/yy to mm/dd/yy) format.
b. Indicate whether the solicitation will be issued within 30 days, 90 days or 6 months after the small business review
PROJECT CONSIDERATIONS (ITEMS 6 – 12)
6. Enter appropriate North American Industrial Classification System (http://www.census.gov/eos/www/naics/index.html). Enter either the applicable Number of Employees or Average Annual Receipts for the specified NAICS.
7. Check box for “New Requirement” if this is a first time acquisition for products/services.
Check box for “Recompetition” if this is a recompetition of a previous acquisition.
Check box for “Similar Requirement” if this is an acquisition that is similar in scope and technical requirements.
Enter history. For Type of Ownership, list SDB, 8(a), SB, WOSB, VOSB, SDVOSB or HUBZone as applicable. You may use the Central Contractor Registration (CCR- http://www.ccr.gov/).

8. Indicate response to Bundling/Consolidation. [Note, FAR 7.104(d)(2) identifies threshold for applicability.] If the total contract value is estimated below this threshold, check N/A. If this requirement is the result of consolidation or bundled requirements, the SBS must concur.


9. Check the appropriate box(es) indicating all resources utilized to identify potential sources that support the acquisition method recommended in Item 10. Include/Attach supporting documentation for each effort. [Note: SBS will not accept market surveys conducted more than 12 months prior to date of this requirement.]
10. CO/CS/COTR/PA – Check the appropriate box(es) indicating the acquisition method determined.  If the procurement is 8(a) and $100,000 or more, include a copy of the SBA offering letter in accordance with FAR Part 19.804-2 (http://www.arnet.gov/far/loadmainre.html).
11. Check appropriate box and refer to FAR 5.202 to indicate the specific exemption.
12. CO/CS/COTR/PA – Check yes or no where other considerations apply. See FAR 19.702(a)(1) and (2) to determine if a Subcontracting Plan is required. A Subcontracting Plan is required if the CO/CS/COTR anticipates that the estimated cost may exceed $550,000 ($1,000,000 for construction). If NO for Subcontracting Plan and/or SDB Plan, attach the approved waiver and supporting documentation -See FAR 19.705-2(c). HHS SBS and SBA PCR concurrence is required.

PROJECT REVIEW & APPROVAL (ITEMS 13 – 15)

13. The Contracting Official (CO) who has the authority to bind the government will make a determination, sign and date.

14. The HHS SBS will sign, date and indicate concurrence or non-concurrence with the method of acquisition determined by the CO. If the HHS SBS does not concur, another method will be recommended (see SBS comments).

15. The SBA PCR shall sign and date this block to indicate concurrence or non-concurrence of the acquisition method determined by the CO. If the SBA PCR does not concur, the rationale will be documented on page 3 of this form and it will include a recommendation. If necessary, the SBA PCR will initiate an appeal process (SBA Standard Form-70) and forward supporting documentation to the CO.





NOTE: In order for the HHS Small Business Specialist to conduct a comprehensive review of each acquisition, at a minimum, the documentation forwarded by the CO/CS/COTR/PA should include:
1. Completed HHS Form 653 signed by the Contracting Official

2. Completed Request for Contract (RFC)/Acquisition Plan (AP) or Request for Quote (RFQ) package. Package must include:

a. The statement of work, including evaluation criteria and the Government cost estimate.

b. Documentation which reflects market research conducted within the past 12 months.



c. If 8(a) procurement $100,000 or greater, attach the SBA Offering Letter. You may visit SBA’s website to identify the SBA District Office that corresponds to your contracting office (http://www.sba.gov/localresources/index.html) .

      1. A copy of the justification for other than small business consideration applicable to the subject acquisition plan.

      2. A copy of the Justification for Other than Full & Open Competition (JOFOC) & supporting documentation, if applicable.




HHS 653 - SMALL BUSINESS REVIEW FORM - Comments

HHS OSDBU Small Business Specialist Comments:

Name: __________________________________________________________ Date: ______________________________


SBA Procurement Center Representative Comments:

Name: ____________________________________________________________ Date: ______________________________





HHS Form 653 (Revised April 2009)


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