DEPARTMENT OF HEALTH & HUMAN SERVICES

National Institute of Health

Bethesda, MD 20892

TECHNICAL EVALUATION REPORT

(EXAMPLE FORMAT- Use this format to send your report to the CS/CO)

To: (Insert CO/CS name and Title)

From: (Insert name of the Chairperson) Technical Evaluation Panel Chairperson

Subject: Solicitation Number: (Insert Solicitation number and Description of Services)

1. Technical evaluation of the proposals submitted in response to the subject

solicitation has been completed. Proposals were evaluated by the following
personnel in accordance with the technical evaluation criteria contained in the
solicitation.
Note: If the technical evaluation panel contained both voting members and advisory
members, please list them separately.

i) ____________________________ ______________________
Name Signature

ii) ____________________________ _______________________

Name Signature

iii) ____________________________ _______________________

Name Signature

iv)____________________________ _______________________
Name Signature

2. In accordance with the solicitation, the criteria used by the committee for the
technical evaluation of proposals are the following:

(Insert Evaluation Criteria)

1.
2.
3.
4.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

3. The following offeror’s submitted technical proposals, listed in descending order

of merit, that are considered technically acceptable:

Firm or Institution Numerical Rating (0-100 points)

i) ______________________________ _________________________
Name Total number of Points

ii) ______________________________ _________________________

Name Total number of Points

4. The following organizations submitted proposals that are considered technically

unacceptable.

Firm or Institution Numerical Rating (0-100 points)

i) ______________________________ _________________________
Name Total number of Points

5. Individual evaluation sheets for each proposal have been completed by each
evaluator (Exhibit I). These evaluation sheets indicate the numerical ratings
assigned to each proposal, adequately supported by comments indicating the
strengths and weakness found in each proposal. A composite evaluation sheet
(Exhibit II) indicating the total scores for each proposal from each evaluator, and
the average score, has also been completed. The individual evaluation sheets,
composite evaluation and this report are being furnished to you for inclusion in
the official contract file.

6. The following narrative summarizes the strengths and weaknesses found in each
proposal and reservations or qualifications that might impact discussions and bear
on the Contracting Officer’s decision to award to that firm. Concrete technical
reasons based on the evaluation criteria must be provided to support all
determinations of acceptability or unacceptability.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

7. A completed Conflict of Interest Statement and Non-Disclosure Statement

(Exhibit III) and Federal Procurement Integrity Act Certification(Exhibit IV) for
each technical evaluation panel member are attached to this report.

Signature:

_____________________________________
Technical Evaluation Chairperson

Attachments:

● Exhibit-I Completed Individual Evaluation Sheets from each evaluator

● Exhibit-II Completed Composite Evaluation Sheet
● Exhibit-III Completed Confidentiality Agreement and Conflict of Interest
Statements from each evaluator

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EXHIBIT I
INDIVIDUAL EVALUATION SHEETS

SUMMARY SHEET FOR EACH PROPOSAL

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

Please note that a perfect score for a criterion means that the offeror does not have any
weaknesses in that area.

Evaluation Criteria Maximum Points Assigned Score

(Insert Evaluation Criteria) (Insert Max Points) (Insert score assigned)

1.
2.
3.
4
5.

Total 100 ______________

Is this Proposal Technically Acceptable (Yes or No)? ______________

Name of Evaluator: ______________________________

(Print or Type)

Signature: ________________________________

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EVALUATION SHEET FOR EACH INDIVIDUAL EVALUATION CRITERIA

Note: Evaluators must complete an evaluation sheet for each criterion and for each
offeror. Please write complete sentences for both strengths and weaknesses to support
your score.

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

EVALUATION CRITERIA:

1. (Insert Evaluation Criteria 1) (Insert Points available)Points

(Insert Evaluation Criteria-1 as written in the solicitation Section M)

Points Available: (Insert Points available) Points Assigned: (Insert Points assigned)

Strengths:

Weaknesses/Deficiencies:

Note: Any requests for clarification resulting from technical proposal review must
be provided to the contract specialist so they may be addressed.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EVALUATION SHEET FOR EACH INDIVIDUAL EVALUATION CRITERIA

Note: Evaluators must complete an evaluation sheet for each criterion and for each
offeror. Please write complete sentences for both strengths and weaknesses to support
your score.

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

EVALUATION CRITERIA:

2. (Insert Evaluation Criteria 2) (Insert Points available)Points

(Insert Evaluation Criteria-2 as written in the solicitation Section M)

Points Available: (Insert Points available) Points Assigned: (Insert Points assigned)

Strengths:

Weaknesses/Deficiencies:

Note: Any requests for clarification resulting from technical proposal review must
be provided to the contract specialist so they may be addressed.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EVALUATION SHEET FOR EACH INDIVIDUAL EVALUATION CRITERIA

Note: Evaluators must complete an evaluation sheet for each criterion and for each
offeror. Please write complete sentences for both strengths and weaknesses to support
your score.

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

EVALUATION CRITERIA:

3. (Insert Evaluation Criteria 3) (Insert Points available)Points

(Insert Evaluation Criteria-3 as written in the solicitation Section M)

Points Available: (Insert Points available) Points Assigned: (Insert Points assigned)

Strengths:

Weaknesses/Deficiencies:

Note: Any requests for clarification resulting from technical proposal review must
be provided to the contract specialist so they may be addressed.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EVALUATION SHEET FOR EACH INDIVIDUAL EVALUATION CRITERIA

Note: Evaluators must complete an evaluation sheet for each criterion and for each
offeror. Please write complete sentences for both strengths and weaknesses to support
your score.

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

EVALUATION CRITERIA:

4. (Insert Evaluation Criteria 4) (Insert Points available)Points

(Insert Evaluation Criteria-4 as written in the solicitation Section M)

Points Available: (Insert Points available) Points Assigned: (Insert Points assigned)

Strengths:

Weaknesses/Deficiencies:

Note: Any requests for clarification resulting from technical proposal review must
be provided to the contract specialist so they may be addressed.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EVALUATION SHEET FOR EACH INDIVIDUAL EVALUATION CRITERIA

Note: Evaluators must complete an evaluation sheet for each criterion and for each
offeror. Please write complete sentences for both strengths and weaknesses to support
your score.

Solicitation Number: (Insert Solicitation no. and description of Services)

OFFEROR: (Insert Offeror’s name)

EVALUATION CRITERIA:

5. (Insert Evaluation Criteria 5) (Insert Points available)Points

(Insert Evaluation Criteria-5 as written in the solicitation Section M)

Points Available: (Insert Points available) Points Assigned: (Insert Points assigned)

Strengths:

Weaknesses/Deficiencies:

Note: Any requests for clarification resulting from technical proposal review must
be provided to the contract specialist so they may be addressed.

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EXHIBIT II

COMPOSITE EVALUATION SHEET

Solicitation Number: (Insert solicitation number and Description of Services)

Name of Panel Panel Panel Panel Average

Offeror Member Member Member Member Score
#1 #2 #3 #4
Total Score Total Score Total Score Total Score

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EXHIBIT III

CONFLICT OF INTEREST AND NON-DISCLOSURE STATEMENT

I acknowledge that I have been selected to participate in the source selection of
Solicitation Number: (Insert solicitation no. and Description of Services). I certify that
I will not knowingly disclose any contractor bid or proposal or source selection
information directly or indirectly to any person other than a person authorized by the
Head of the Contracting Activity or the Contracting Officer (CO) to receive such
information. I understand that unauthorized disclosure of such information may subject
me to substantial administrative, civil and criminal penalties, including fines,
imprisonment, and loss of employment under the Procurement Integrity Law or other
applicable laws and regulations.
To the best of my knowledge, I certify that neither I nor my spouse, my dependent
children, members of my household, nor personnel with whom I am seeking
employment:
a. Have any direct or indirect financial interest in any of the firms submitting
proposals or their proposed subcontractors, or
b. Have any other beneficial interest in such firms except as fully disclosed on an
attachment to this certification.
I further affirm that in the event that any business entity, either as a prime or
subcontractor, in which I, or a member of my family or household, have holdings,
financial interest, or an employment relationship, of whatever nature and to whatever
extent, submits a proposal in response to this solicitation that I will notify the CO in
writing and withdraw from participation in the evaluation.
I certify that I will not discuss with, or reveal to, any representative of any business
organization or other entity, or any individual person (except persons specifically
assigned to my specific proposal evaluation group) either within or without the United
States Government, any aspects of the pending procurement. The term "any aspects of
the pending procurement" includes, but is not limited to, information such as the identity
and number of Contractors, the method of procurement, the number and identity of
Government personnel involved, and the schedule of key technical and procurement
events in the source selection process. Except as specifically authorized by the CO, the
release of such information constitutes the unauthorized release of advance procurement
or procurement information. I recognize that a significant factor in the successful and
proper completion of the source selection process is the strict confidentiality observed by
all Government participants in the various proposal evaluation and evaluation review
groups concerning all of the activities and procedures involved in source selection and
that failure to comply with these requirements may compromise the ultimate source

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

selection. I acknowledge that the unauthorized release of advance procurement or

procurement information as defined herein may result in the termination of my
participation in this procurement. In the event I release any of the advance procurement
or procurement information covered hereby, I agree to so advise the senior member of the
proposal evaluation or proposal evaluation review group to which I am assigned as soon
as practicable. That advice will identify the business organization or other entity, or
individual person, to whom the information in question was divulged and the content of
that information.

Printed Name:

Signature:
Position:

Organization: Date:

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

EXHIBIT IV
FEDERAL PROCUREMENT INTEGRITY ACT

Subsection 27(d)(7)(A) of the Office of Federal Procurement Policy Act, 41 U.S.C. 423
(hereinafter the Act), and Sections 3.104-1 through 3.104-9 of the Federal Acquisition
Regulation (FAR), require certification that individuals who participate in the preparation
and/or submission of bids and/or offers for which the undersigned has participated or will
participate in personally and substantially declare that they are familiar with and will
comply with the requirements of subsection 27(a) of the Act and FAR 3.104-3 as follows:
During the course of any federal agency procurement of products or services, I
understand and certify that I will observe the following rules of conduct:
a. I will not solicit or accept, directly or indirectly, any promise of future
employment or business opportunity from, or engage, directly or indirectly, in any
discussion of future employment or business opportunity with, any officer,
employee, representative, agent, or consultant of a competing offeror.
b. I will not ask for, demand, exact, solicit, seek, accept, receive, or agree to receive,
directly or indirectly, any money, gratuity, or other thing of value from any
officer, employee, representative, agent, or consultant of any competing offeror
for this acquisition. I will advise my family that the acceptance of any such
gratuity may be imputed to me as a violation, and must therefore be avoided.
c. I will not discuss proposal evaluation or source selection matters with any
unauthorized individuals (including Government personnel), even after contract
award, without specific prior approval from proper authority.
d. I understand that my obligations under this certification are of a continuing
nature. If at any time during the source selection process, I receive a contract from
a competing offeror concerning employment or other business opportunity, the
offer of a gift from a competing offeror, or I encounter circumstances where my
participation might result in a real, apparent, or potential conflict of interest, I will
immediately seek the advice of an Ethics Counselor and report the circumstances
to the Source Selection Authority.

I understand that making a false, fictitious, or fraudulent certification may subject me to

prosecution under Title 18, United States Code, Section 1001

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 DEPARTMENT OF HEALTH & HUMAN SERVICES
National Institute of Health
Bethesda, MD 20892

Printed Name:

Signature:

Position:

Organization: Date:

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