114901-O4.pdf

STATE OF NEBRASKA CONTRACT AWARD

PAGE PRINT DATE

1 of 2 12/3/2025

BUSINESS UNIT BUYER

25480018 LENEDDA ESQUIVEL (DHHS) CONTRACT NUMBER

VENDOR NUMBER: 3126055 114901 O4

VENDOR ADDRESS:

STACEY ROODE

DBA NEBRASKA MEDICINE

215 S 150TH ST

OMAHA NE 68154-2016

AN AWARD HAS BEEN MADE TO THE VENDOR NAMED ABOVE FOR THE PERSONAL PROPERTY AND/OR SERVICES AS LISTED

BELOW FOR THE PERIOD:

DECEMBER 08, 2025 THROUGH AUGUST 02, 2027

THIS CONTRACT IS NOT AN EXCLUSIVE CONTRACT TO FURNISH THE PERSONAL PROPERTY AND/OR SERVICES SHOWN BELOW, AND DOES NOT PRECLUDE THE PURCHASE OF SIMILAR SERVICES FROM OTHER SOURCES.

THE STATE RESERVES THE RIGHT TO EXTEND THE PERIOD OF THIS CONTRACT BEYOND THE TERMINATION DATE WHEN

MUTUALLY AGREEABLE TO THE VENDOR/CONTRACTOR AND THE STATE OF NEBRASKA.

Original/Bid Document 109205 O3

AGENCY SIGNATURE

R43500|NISK0001|NISK0001 20210628

Contract to supply and deliver Registered Nurse Trauma Review services to the State of Nebraska as per the attached specifications for a twenty (20) month period from date of award. The contract may be renewed for two (2) additional one (1) year periods when mutually agreeable to the vendor and the State of Nebraska.

This is the initial term of the contract.

Vendor Point of Contact:

Name: Stacey Lynne Roode Phone: 402.618.0375 E-Mail: sroode@nebraskamed.com

(LDE 12/3/2025)

Line Description Quantity Unit of

Measure Unit Price

Extended Price

1 GENERAL AND ADVANCED TRAUMA

RN

25,000.0000 $ 1.0000 25,000.00

INITIAL TERM 12/8/25 - 8/2/27

2 BASIC TRAUMA CENTER RN 25,000.0000 $ 1.0000 25,000.00

INITIAL TERM 12/8/25 - 8/2/27

3 OPT RENEWAL 1 GEN AND ADV RN 10,000.0000 $ 1.0000 10,000.00

8/3/27 - 8/2/28

4 OPT RENEWAL 1 BASIC TRAUMA RN 10,000.0000 $ 1.0000 10,000.00

8/3/27 - 8/2/28

5 OPT RENEWAL 2 GEN AND ADV RN 10,000.0000 $ 1.0000 10,000.00

8/3/28 - 8/2/29

Docusign Envelope ID: 5EA758F1-9A41-430F-86DC-9410E42E8770

12/3/2025 | 17:11:32 CST

STATE OF NEBRASKA CONTRACT AWARD

PAGE PRINT DATE

2 of 2 12/3/2025

BUSINESS UNIT BUYER

25480018 LENEDDA ESQUIVEL (DHHS) CONTRACT NUMBER

VENDOR NUMBER: 3126055 114901 O4

INITIALS

R43500|NISK0001|NISK0001 20210628

Line Description Quantity Unit of

Measure Unit Price

Extended Price

6 OPT RENEWAL 2 BASIC TRAUMA RN 10,000.0000 $ 1.0000 10,000.00

8/3/28 - 8/2/29

Total Order 90,000.00

10/22/2021 rab

Trauma Review RFQ 109205 O3 Checklist Stacey Roode submittal

This checklist is a tool to help people through the application process to become part of the qualified pool of Trauma Reviewers using the Request for Proposal (RFQ) 109205-O3. Using this checklist will help you gather all of the required documents.

Included Documents Secretary of State/Tax Commissioner Registration Requirements (firm) or United States Citizenship

Attestation Form (individual) Attachment 1, Request for Qualifications for Contractual Services Form

Attachment 2, Trauma Reviewer and Consultant Qualifications (Individual or Firm)

Supporting Documentation for Attachment 2

Documentation must be provided for each of the qualifications.

N/A Separate documentation required for General and Basic Trauma Center Qualifications if applicable

Proof of Insurance per section V.G

Complete Vendor Application with ACH payment (required)

Include copy of voided check or statement from bank (required)

Link for the Vendor/ACH application: https://das.nebraska.gov/accounting/forms/ACH__W9_Fillable.pdf

Link to Trauma Review for Proposal 109205-O3: https://das.nebraska.gov/materiel/purchasing/109205/109205.html

Send questions or inquiries to: dhhs.rfpquestions@nebraska.gov https://das.nebraska.gov/accounting/forms/ACH__W9_Fillable.pdf https://das.nebraska.gov/materiel/purchasing/109205/109205.html mailto:dhhs.rfpquestions@nebraska.gov

EVALUATION

TRAUMA REVIEWER AND CONSULTANT QUALIFICATIONS - INDIVIDUAL

1. Surgeon Reviewer

Applicant Name:

Email Address:

License #:

Qualifications

General Trauma Center Qualification Basic Trauma Center Qualification

Pass Fail Pass Fail

Trauma Surgeon with an unencumbered license and no current disciplinary action

At least two (2) years of experience and active involvement in trauma care

Board certified eligible in their field N/A N/A

Board certified/eligible in General Surgery or surgical subspecialty.

N/A N/A

ATLS certified and current (provide copy of current certification, instructor card, or evidence of instructor status)

2. PHYSICIAN REVIEWER

Applicant Name:

Email Address:

License #:

Qualifications Basic Trauma Center Qualification

Pass Fail

Physician with an unencumbered license and no current disciplinary action

At least 2 years of experience and active involvement in trauma care or equivalent experience, such as Emergency Medicine Physician.

Board certified eligible in their field

ATLS certified and current (provide copy of current certification, instructor card, or evidence of instructor status)

3. TRAUMA NURSE REVIEWER

Applicant Name: Stacey Roode

Email Address: sroode@nebraska.com

License #: 67020

Qualifications General and Advanced Trauma Center Qualification

Basic Trauma Center Qualification

Pass Fail Pass Fail

Registered Nurse with an unencumbered license and no current disciplinary action

X X

At least two (2) years of trauma program staff experience at the general, advanced or comprehensive level trauma center and active involvement in trauma care

X N/A N/A

At least two (2) years of trauma program staff experience at the basic, general, advanced or comprehensive level trauma center and active involvement in trauma care

N/A N/A X

Current TNCC (provide copy of current certification, instructor card, or evidence of instructor status). Equivalent courses include ATCN and TPATC.

X X

Certificate Of Completion Envelope Id: 5EA758F1-9A41-430F-86DC-9410E42E8770 Status: Completed

Subject: Complete with Docusign: 114901.pdf

Envelope Type: Contract

Envelope Name: 114901-04 Trauma Reviewer RN

Divison:

DHHS Sender: LeNedda Esquivel

DHHS Sharepoint ID:

FFATA Reporting Required:

Source Envelope:

Document Pages: 8 Signatures: 1 Envelope Originator:

Certificate Pages: 5 Initials: 1 LeNedda Esquivel

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-06:00) Central Time (US & Canada)

301 Centennial Mall S

Lincoln, NE 68508-2529

LeNedda.Esquivel@nebraska.gov

IP Address: 164.119.5.88

Record Tracking Status: Original

12/3/2025 3:05:17 PM

Holder: LeNedda Esquivel

LeNedda.Esquivel@nebraska.gov

Location: DocuSign

Security Appliance Status: Connected Pool: StateLocal

Storage Appliance Status: Connected Pool: Nebraska Department of Health & Human

Services

Location: Docusign

Signer Events Signature Timestamp Ashley Newmyer ashley.newmyer@nebraska.gov

Interim Director, Public Health

Department of Health & Human Services

Security Level: Email, Account Authentication (None)

Signature Adoption: Pre-selected Style

Using IP Address: 164.119.5.1

Sent: 12/3/2025 3:11:12 PM

Viewed: 12/3/2025 5:10:48 PM

Signed: 12/3/2025 5:11:32 PM

Electronic Record and Signature Disclosure:

Accepted: 2/12/2019 11:56:49 AM ID: 63e7a92c-29a2-4e4c-b983-4104e52163f0

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp Jan Wagner jan.wagner@nebraska.gov

Security Level: Email, Account Authentication (None)

Sent: 12/3/2025 3:11:12 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Carbon Copy Events Status Timestamp LeNedda Esquivel

LeNedda.Esquivel@nebraska.gov

Administrator II

DHHS

Security Level: Email, Account Authentication (None)

Sent: 12/3/2025 5:11:33 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Sherri Wren sherri.wren@nebraska.gov

Program Manager

Security Level: Email, Account Authentication (None)

Sent: 12/3/2025 5:11:33 PM

Electronic Record and Signature Disclosure:

Accepted: 12/20/2023 8:39:55 AM ID: 00a7667a-dd88-4382-aac7-b84c6869b246

Stacey Roode sroode@nebraskamed.com

Security Level: Email, Account Authentication (None)

Sent: 12/3/2025 5:11:33 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 12/3/2025 3:11:12 PM

Certified Delivered Security Checked 12/3/2025 5:10:48 PM

Signing Complete Security Checked 12/3/2025 5:11:32 PM

Completed Security Checked 12/3/2025 5:11:33 PM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

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Electronic Record and Signature Disclosure created on: 2/11/2018 10:43:44 PM Parties agreed to: Ashley Newmyer, Sherri Wren

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Summary