<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 15%" />
<col style="width: 14%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 9%" />
<col style="width: 12%" />
<col style="width: 4%" />
<col style="width: 21%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><p><strong>U.S. Department of
Transportation</strong></p>
<p><strong>Small Business Program Review Form</strong></p></td>
<td colspan="2">Date: _________</td>
</tr>
<tr class="even">
<td colspan="14"><strong>Part I PROGRAM OFFICE</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><ol type="1">
<li><p>Office Routing Symbol _____</p></li>
</ol></td>
<td colspan="3"><ol start="2" type="1">
<li><p>Requestor's Name:</p></li>
</ol>
<p>___________________</p></td>
<td colspan="2"><ol start="3" type="1">
<li><p>Phone No.:</p></li>
</ol>
<p>_____________</p></td>
<td colspan="3"><ol start="4" type="1">
<li><p>Procurement Request Number: _____________</p></li>
</ol></td>
<td colspan="2"><ol start="5" type="1">
<li><p>Estimated Dollar Value: $_________</p></li>
</ol></td>
</tr>
<tr class="even">
<td colspan="14"><ol start="6" type="1">
<li><p>Description of the Acquisition (state if previously
set-aside)</p></li>
</ol></td>
</tr>
<tr class="odd">
<td colspan="5" rowspan="2"><ol start="7" type="1">
<li><p>Please Check as appropriate:</p></li>
</ol></td>
<td></td>
<td colspan="5">New Requirement (Go to Part III)</td>
<td colspan="3" rowspan="2"><ol start="8" type="1">
<li><p>Recommended method of procurement (Select one from Part
III)</p></li>
</ol>
<p>__________________________________</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="5">Bundled Acquisition (if checked, complete Parts III and
IV) See Instructions for definition</td>
</tr>
<tr class="odd">
<td colspan="8"><p><strong>Part II ACQUISITION HISTORY</strong></p>
<p>If previously awarded, check all that apply</p></td>
<td colspan="6"><p><strong>Part III CO/SBS RECOMMENDATION</strong></p>
<p>Check all that apply</p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">Small Business</td>
<td colspan="2"></td>
<td colspan="4">Small Business Set-Aside</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Small Disadvantaged Business</td>
<td colspan="2"></td>
<td colspan="4">SBA 8(a) Set-aside</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">8(a) Business</td>
<td colspan="2"></td>
<td colspan="4">HUBZone Set-Aside</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Woman Owned Business</td>
<td colspan="2"></td>
<td colspan="4">Very Small Business Set-Aside</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">Service Disabled Veteran Owned Business</td>
<td colspan="2"></td>
<td colspan="4">Task Order/Delivery Order **</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Veteran Owned Business</td>
<td colspan="2"></td>
<td colspan="4">GSA/FSS Order</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">HUBZone Business</td>
<td colspan="2"></td>
<td colspan="4">Woman Owned Business</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">GSA/FSS Order</td>
<td colspan="2"></td>
<td colspan="4">Service Disabled Veteran Owned Business</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">Large Business</td>
<td colspan="2"></td>
<td colspan="4">Large Business with Subcontracting Goals</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Sole Source</td>
<td colspan="2"></td>
<td colspan="4">Bundled Acquisition (complete Part IV)</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6">Task Order/Delivery Order</td>
<td colspan="2"></td>
<td colspan="4">Sole Source</td>
</tr>
<tr class="odd">
<td colspan="8" rowspan="2"><ol start="9" type="1">
<li><p>Contract No.: __________________________________</p></li>
</ol>
<p>Contractor Name: _________________________________</p>
<p>Program Official's Signature: ________________________</p>
<p>Date: _____________</p></td>
<td colspan="2"></td>
<td colspan="4">Other (Specify)</td>
</tr>
<tr class="even">
<td colspan="6"><ol start="10" type="1">
<li><p>Small Business Size Standard:</p></li>
</ol>
<p>NAICS Code _________________ (See 13CFR121)</p>
<p>Employees ______ OR Dollars _____________</p></td>
</tr>
<tr class="odd">
<td colspan="14"><p><strong>Part IV BUNDLED ACQUISITIONS</strong></p>
<p>(Not required for Acquisitions Entirely Reserved or Set-Aside for
Small Businesses)</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="13">Under $2M (justify see TAM 1207.103)</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="13">Over $2M (justify see TAM 1207.103)</td>
</tr>
<tr class="even">
<td colspan="14"><strong>Part V SB PROGRAM RECOMMENDATION -
CONCURRENCE/APPROVALS</strong></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>Concur</strong></td>
<td colspan="2"><strong>Non-Concur</strong></td>
<td colspan="8"><ol start="11" type="1">
<li><p>Contracting Officer's Recommendation</p></li>
</ol>
<p>Signature:_____________________________ Date: :
_______________</p></td>
<td><p>Attach justification if non-set-aside/bundled acquisition.</p>
<p>Attach justification if non-concur.</p></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="8"><ol start="12" type="1">
<li><p>Small Business Specialist (SBS)</p></li>
</ol>
<p>Signature:_____________________________ Date: :
_______________</p></td>
<td><p><strong>Small Business Set-Aside</strong></p>
<p>(if checked and SBS concurs, this constitutes approval and no further
coordination required)</p></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="8"><ol start="13" type="1">
<li><p>SBA Procurement Center Representative (PCR)</p></li>
</ol>
<p>Signature:_____________________________ Date: :
_______________</p></td>
<td>Attach justification if non-concur.</td>
</tr>
<tr class="even">
<td colspan="3"><strong>Approve</strong></td>
<td colspan="2"><strong>Disapprove</strong></td>
<td colspan="8"><ol start="14" type="1">
<li><p>Director OSDBU</p></li>
</ol>
<p>Signature:_____________________________ Date: :
_______________</p></td>
<td>Attach justification if disapproved</td>
</tr>
</tbody>
</table>