+-----------------------------------------------------------------------+
| **HHS SMALL BUSINESS REVIEW FORM**                                    |
|                                                                       |
| Office of Small and Disadvantaged Business Utilization (OSDBU)        |
| Control Number , if applicable:                                       |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                |
|                                                                       |
| Date Received:                                                        |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_          |
+-----------------------------------------------------------------------+
| **A. Project Information**                                            |
+-----------------------------------------------------------------------+

+-----------------------------+-----------------------------------------+
| 1\. Solicitation Number:    | 2\. Acquisition Office and OPDIV:       |
| \_\_\_\_\_\_\_\             |                                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_ | > CO/CS/PA Name:                        |
|                             | >                                       |
| > Acquisition Instrument    | > Location (Bldg. and Room):            |
| > Proposed/Contract Type:   | >                                       |
| >                           | > Contact Information (Telephone, Fax   |
| > \[ \] Contract No:        | > and E-mail):                          |
| > \_\_\_\_\_\_\_\_\_\       |                                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                         |
| >                           |                                         |
| > \[ \] Departmental IDIQ   |                                         |
| > No:                       |                                         |
| > \_\_\                     |                                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                         |
| >                           |                                         |
| > \[ \] GSA Schedule No:    |                                         |
| > \_\_\_\_\_\               |                                         |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_ |                                         |
| >                           |                                         |
| > \[ \] GWAC Contract No:   |                                         |
| > \_\_\_\_\_                |                                         |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\ |                                         |
| > \[ \] HHS BPA (Strategic  |                                         |
| > Sourcing):\               |                                         |
| > \[ \] HHS BPA Waiver (See |                                         |
| > instructions)             |                                         |
| >                           |                                         |
| > \[ \] Listed on the HHS   |                                         |
| > Forecast                  |                                         |
+-----------------------------+-----------------------------------------+

+----------------------------+-----------------------------------------+
| 3\. Brief description of   | 4\. Total Estimated Dollar Value        |
| services or products to be | (Including Options): \$                 |
| procured:                  | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_          |
|                            |                                         |
|                            | Base: \$                                |
|                            | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  |
|                            | Options: \$                             |
|                            | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_  |
+----------------------------+-----------------------------------------+
|                            | 5\. Date of Period of Performance       |
|                            | (including Options) or Delivery Date:   |
+----------------------------+-----------------------------------------+

  -----------------------------------------------------------------------
  **B. Project Considerations**

  -----------------------------------------------------------------------

+------------------------------+---------------------------------------+
| 6\. NAICS Code:              | 7\. \[ \] New Requirement \[ \]       |
| [\_\_\_\                     | Recompetition \[ \] Similar           |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\ | Requirement                           |
| _\_\_\_\_\_\_\_]{.underline} |                                       |
|                              | **Acquisition History:**              |
| Dollars:                     |                                       |
| \_\_                         | Previous Contract Number:             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ | \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Award    |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ | Date: \_\_\_\_\_\_\_\_\_\_            |
|                              |                                       |
| No. of Employees:            | Total Amount of Contract Award:       |
| \_\_\_\_\_\_\_\_             | \_\_\_\_\_\_\_\_\_\_\_\_\             |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |                                       |
|                              | Contractor Name:                      |
|                              | \_\_\_\_\_\_                          |
|                              | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |                                       |
|                              | Contractor Size/Type of Ownership:    |
|                              | \_\_\_\_\_\_\_\_\_\_\                 |
|                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |                                       |
|                              | Previous/NAICS Code/Size Standard:    |
|                              | \_\_\_\_\_\_\_\_\                     |
|                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                              |                                       |
|                              | Number of Technically Acceptable      |
|                              | 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     | 10\. Acquisition Method(s)          |
| sources within last 12 months: |                                     |
|                                | \[ \] 8(a) Sole Source              |
| > CO SBS                       |                                     |
| >                              | \[ \] 8(a) Competitive              |
| > \[ \] \[ \] Review of Prior  |                                     |
| > or Similar Acquisition       | \[ \] HUBZone Set-Aside             |
| >                              |                                     |
| > \[ \] \[ \] Contracting      | \[ \] HUBZone Competitive           |
| > Officer                      |                                     |
| >                              | \[ \] Service-Disabled              |
| > \[ \] \[ \] Program Office   | Veteran-owned (SDVOSB)              |
| >                              |                                     |
| > \[ \] \[ \] FedBizOpps       | \[ \] Total Small Business          |
| > Sources Sought (**Copy       | Set-Aside                           |
| > Attached**)                  |                                     |
| >                              | \[ \] Partial Small Business        |
| > \[ \] \[ \] Market Survey    | Set-Aside                           |
| > (**See Attached**)           |                                     |
| >                              | \[ \] Buy Indian Act (25 USC 47)    |
| > \[ \] \[ \] Consult HHS      |                                     |
| > Small Business Specialist    | \[ \] Urban Indian Organization     |
| >                              | (P.L. 94-437) (IHS only)            |
| > \[ \] \[ \] Central          |                                     |
| > Contractor Registration      | \[ \] JOFOC (Authority):            |
| > (CCR)                        | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\   |
| >                              | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| > \[ \] \[ \] Other:           |                                     |
| > \_\_\_\_\_\_\_\_\_\_         | \[ \] No Reasonable expectation of  |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ | obtaining 2 or more SB offers.      |
|                                |                                     |
|                                | \[ \] Other (explain):              |
|                                | \_\_                                |
|                                | \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |
|                                | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+--------------------------------+-------------------------------------+

+--------------------+-------------------------------------------------+
| 11\. Synopsis:     | 12\. Other Considerations that apply to the     |
|                    | Solicitation:                                   |
| > \[ \] Yes        |                                                 |
| > (FEDBIZOPPS)     | > Yes No Yes No                                 |
| >                  | >                                               |
| > \[ \] No. Per    | > \[ \] \[ \] Subcontracting Plan (i*f no, see  |
| > FAR 5.202        | > instructions)* \[ \] \[ \] SDB Plan           |
| > \_\_\_\_\_\_     | >                                               |
| >                  | > \[ \] \[ \] Green Contracting Considerations  |
| > \[ \]            |                                                 |
| > Othe             | Other:                                          |
| r:\_\_\_\_\_\_\_\_ | [\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\        |
| \_\_\_\_\_\_\_\_\_ | _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
|                    | \_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}\_\_\_ |
+--------------------+-------------------------------------------------+

+--------------------+-----------------------+-------------------------+
| **C. Project       |                       |                         |
| Review &           |                       |                         |
| Approval**         |                       |                         |
+--------------------+-----------------------+-------------------------+
| 13\. Contracting   | 14\. Small Business   | 15\. SBA Procurement    |
| Officer:           | Specialist:           | Center Representative:  |
|                    |                       |                         |
| [\_                | \[ \] Concur \[ \]    | \[ \] Concur \[ \]      |
| \_]{.underline}    | Non-concurrence:      | Non-concurrence:        |
| [\_\_\_            |                       |                         |
| \                  | [\_ \_\_]{.underline} | [\_\_\_]{.underline}    |
| _\_\_]{.underline} | [\_\_                 | [\_                     |
|                    | \_\_\_\_]{.underline} | \_\_\_\_\_]{.underline} |
| Signature Date     |                       |                         |
|                    | Signature Date        | Signature Date          |
+--------------------+-----------------------+-------------------------+

+----------------------------------+-----------------------------------+
| **SMALL BUSINESS REVIEW FORM     |                                   |
| INSTRUCTIONS**                   |                                   |
+----------------------------------+-----------------------------------+
| **PROJECT INFORMATION (ITEMS 1   | 9\. Check the appropriate box(es) |
| -- 5)**                          | indicating all of the resources   |
|                                  | used to identify potential        |
| 1\. Enter the solicitation       | sources that support the          |
| number. Indicate acquisition     | acquisition method recommended in |
| instrument/contract type by      | Item 10. Include/Attach           |
| checking appropriate box. Enter  | supporting documentation for each |
| the contract number, if known.   | effort. *\[Note: SBS will not     |
| Indicate the type of SSI waiver: | accept market surveys conducted   |
| Strategic Sourcing Initiative    | more than 12 months prior to date |
| (SSI) or Strategic Sourcing      | of this requirement.\]*           |
| Initiative-Small Business        |                                   |
| (SSI-SB).                        | 10\. CO/CS/PA -- Check the        |
|                                  | appropriate box(es) indicating    |
| 2\. Enter Contracting            | the acquisition method            |
| Officer/Specialist (CO/CS) or    | determined.                       |
| Purchasing Agent's Name, OPDIV,  |                                   |
| Building, Room, Telephone, Fax   | 11\. Check appropriate box and    |
| and e-mail.                      | refer to FAR 5.202 to indicate    |
|                                  | the specific exemption.           |
| 3\. Enter the item/service       |                                   |
| description or project title.    | 12\. CO/CS/PA -- Check yes or no  |
|                                  | where other considerations apply. |
| 4\. Enter the total estimated    | See FAR 19.702(a)(1) and (2) to   |
| dollar value of the contract,    | determine if a Subcontracting     |
| including all options.           | Plan is required. If NO for       |
|                                  | Subcontracting Plan and/or SDB    |
| 5\. Enter the estimated period   | Plan, attach the approved waiver  |
| of performance, including any    | and supporting documentation -See |
| option periods, using (mm/dd/yy  | FAR 19.705-2(c). SBS/SBA          |
| to mm/dd/yy) format.             | concurrence is required.          |
|                                  |                                   |
| **PROJECT CONSIDERATIONS (ITEMS  | **PROJECT REVIEW & APPROVAL       |
| 6 -- 12)**                       | (ITEMS 13 -- 15)**                |
|                                  |                                   |
| 6\. Enter appropriate North      | 13\. The CO will make a           |
| American Industrial              | determination, sign and date.     |
| Classification System (NAICS)    |                                   |
| code. Based on the assigned      | 14\. The SBS sill sign and date   |
| NAICS, enter either the          | this block and indicate           |
| applicable Number of Employees   | concurrence or non-concurrence    |
| or Average Annual Receipts.      | with the method of acquisition    |
|                                  | determined by the CO. If the SBS  |
| 7\. Check box for "New           | doesn't concur, the SBS will      |
| Requirement" if this is a first  | recommend another method of       |
| time acquisition for             | acquisition and forward           |
| products/services.               | supporting documentation to CO.   |
|                                  |                                   |
| Check box for "Recompetition" if | 15\. Only the SBA/PCR shall sign  |
| this is a recompetition of a     | and date this block indicating    |
| previous acquisition.            | concurrence or non-concurrence    |
|                                  | with the method of acquisition    |
| Check box for "Similar           | determined by the CO. If the      |
| Requirement" if this is an       | SBA/PCR doesn't concur, the       |
| acquisition where the technical  | SBA/PCR will document their       |
| requirements and scope are       | rationale on page 3 of this form  |
| similar.                         | and recommend another method of   |
|                                  | acquisition or will initiate the  |
| Enter history. For Type of       | SBA SF 70 appeal process and      |
| Ownership, list SDB, 8(a), SB,   | forward supporting documentation  |
| WOSB, VOSB, SDVOSB or HUBZone as | to the CO.                        |
| applicable.                      |                                   |
|                                  |                                   |
| 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 notify the HHS OSDBU for    |                                   |
| concurrence. Additionally, the   |                                   |
| Project Officer must certify     |                                   |
| (with concurrence at one level   |                                   |
| above) whether or not the action |                                   |
| is bundled in accordance with    |                                   |
| the 4/15/2003 memorandum from    |                                   |
| the Acting Deputy Assistant      |                                   |
| Secretary for Grants and         |                                   |
| Acquisition Management, DHHS. If |                                   |
| the action is bundled, the       |                                   |
| certification must be signed by  |                                   |
| the PO and PO's immediate        |                                   |
| supervisor and included in the   |                                   |
| Request for Contract document.   |                                   |
+----------------------------------+-----------------------------------+

**NOTE:** In order for the HHS Small Business Office to conduct a
comprehensive review of each acquisition, at a minimum, the
documentation forwarded by the CO/CS/PA should include:

1\. Completed HHS Form 653.

2\. Complete Request for Quote (RFQ) or Request for Contract Proposal
(RFP) 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.

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

4.  Copy of the completed Strategic Sourcing Waiver, if applicable.

5.  Acquisition Plan, if applicable.

+----------------------------------------------------------------------+
| **HHS OSDBU SMALL BUSINESS REVIEW FORM - Comments**                  |
+----------------------------------------------------------------------+
| **HHS OSDBU Small Business Specialist Comments:**                    |
|                                                                      |
| **Name:                                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
+----------------------------------------------------------------------+
| **SBA Procurement Center Representative Comments:**                  |
|                                                                      |
| **Name:                                                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_                 |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
| Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_** |
+----------------------------------------------------------------------+