17-Generative_AIDisclosure_Form_(DPR-97B).pdf
PDF 748 KB Posted
- Attached to
- S25650009
- Solicitation number
- 0000038825
- Issued by
- Shasta County, Shasta CDP, Shasta Lake City, Mount Shasta City, California
About this file
This is an Artificial Intelligence (AI) Disclosure Form issued by the California Department of Parks and Recreation (DPR) for use in state and local contract solicitations. The form is designed to identify and track any use of artificial intelligence technology, including generative AI, in products and services proposed by bidders. Bidders are required to complete Section I with their business contact information and a detailed description of services being provided, including specific names of AI products and large language models. Section II requires disclosure of whether AI technology will be used or offered by the bidder or subcontractors, and if so, bidders must specify the type of AI (traditional or generative), whether the AI is required for the product, the specific model and version, the applicable license tier, and the delivery method (IaaS, PaaS, SaaS, or on-premises deployment). The form applies to solicitation S25650009 for Boat Boarding Float Replacement at McArthur-Burney Falls Memorial State Park.
Section III requires bidder certification through signature that all information provided is true and accurate. The form includes comprehensive instructions indicating that if generative AI is disclosed and DPR intends to pursue the product, DPR staff must complete the SIMM 5305-F GenAI Intelligence Risk Assessment and submit it to specified email addresses (ISPO@parks.ca.gov, PMO@parks.ca.gov, and DPR-IT.Procurement@parks.ca.gov) for review. The procurement process will be placed on temporary hold pending California Department of Technology (CDT) approval. The form provides definitions for cloud computing service models (IaaS, PaaS, and SaaS) to assist bidders in accurately characterizing their proposed solutions.
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Text version
State of California – Natural Resources Agency
DEPARTMENT OF PARKS AND RECREATION
ARTIFICIAL INTELLIGENCE (AI) DISCLOSURE FORM
Instructions for this form are on Page 3.
I. BIDDER CONTACT INFORMATION
BUSINESS NAME SOLICITATION NUMBER
REPRESENTATIVE NAME BUSINESS TELEPHONE NUMBER
BUSINESS ADDRESS CITY STATE ZIP CODE
Description of Services:
Describe in detail the services being provided. Include names of products and large language model.
II. DISCLOSURE
Will you and/or your subcontractor(s) be using or offering AI technology, model, service, or system (collectively, “product”) for this product in question?
No. (Skip to Section IIII) Yes. (Answer 1-5 below)
1. What type of AI is included?
Traditional AI Generative AI
2. Is the AI required for this product?
No Yes Other:
DPR 97B (Rev. 6/2025)(Word to PDF 6/18/2025)(Page 1 of 3)
ARTIFICIAL INTELLIGENCE (AI) DISCLOSURE FORM (Continued)
3. What is the model and version of this product?
4. What is the license tier of the AI product, if applicable (free, enterprise, platinum, etc.)?
5. How is the AI solution delivered: IaaS, PaaS, SaaS, or will it be deployed on-premises? (Indicate if this is a thin client, thick client, web extension, plugin, etc.)
Provide the best contact for information related to questions related to the AI included in the product (if different than the representative listed in Section I.)
NAME E-MAIL PHONE NUMBER
III. SIGNATURE
By signing this document, I have identified and reported any AI use in the performance of this product in question.
Signature Date
DPR 97B (Rev. 6/2025)(Page 2 of 3)
ARTIFICIAL INTELLIGENCE (AI) DISCLOSURE FORM (Instructions)
Instructions:
The Department of Parks and Recreation (DPR) is required to track and complete risk assessments for any Generative Artificial Intelligence (GenAI) purchases. This document is intended to help DPR identify GenAI and assess the risk related to any GenAI purchases.
Section I:
Bidders shall fill in their contact information.
The DPR staff shall fill out the Description of Services in detail and/or reference the applicable Statement of Work or attachment(s). Include the services to be provided related to AI and include the names of products and large language model. It is important to include as much detail as possible related to any AI aspect of the potential purchase.
Section II:
Bidders shall disclose any aspect of AI related to the purchase.
If “no” is selected, no further information is required in this section.
If “yes” is selected, the Bidder shall fill out answers to questions 1-5. Bidders should provide as much detail as possible related to the AI technology, model, service or system as it relates to what the DPR is soliciting for.
If GenAI is selected and the DPR staff intends to pursue the product, the DPR staff must complete the SIMM 5305-F GenAI Intelligence Risk Assessment, Data Classification section and the Risk Assessment Questionnaire questions a-j; and submit it to ISPO@parks.ca.gov with a cc: to both PMO@parks.ca.gov and DPR-IT.Procurement@parks.ca.gov. Contact ISPO@parks.ca.gov for assistance with completing this assessment.
Upon review, ISPO will contact the DPR staff for more information, if needed, prior to submitting the finalized document to the California Department of Technology.
Procurement efforts will be placed on temporary hold pending CDT approval.
Definitions:
IaaS – Infrastructure as a Service is a cloud computing model that provides on-demand access to virtualized computing resources like servers, storage, and networking.
PaaS – Platform as a Service is a cloud computing model that provides a complete platform for developing, running, and managing applications.
SaaS – Software as a Service a cloud-based software delivery model where users access and use applications over the internet via a subscription rather than purchasing and installing software locally.
Section III:
Bidder signatures are required to certify all provided information on this document is true and accurate to the best of their knowledge.
DPR 97B (Rev. 6/2025)(Page 3 of 3) https://cdt.ca.gov/wp-content/uploads/2025/01/SIMM-5305-F-GenAI-Risk-Assessment-2025_0131-final.pdf mailto:ISPO@parks.ca.gov mailto:ISPO@parks.ca.gov mailto:PMO@parks.ca.gov mailto:DPR-IT.Procurement@parks.ca.gov
| ARTIFICIAL INTELLIGENCE (AI) DISCLOSURE FORM |
| I. |
| II. |
| Describe in detail the services being provided. Include names of products and large language model. |
| 4. |
| SIGNATURE |
| III. |
| Name and description of productservice: |
| BUSINESS NAME: |
| BUSINESS ADDRESS: |
| STATE: |
| ZIP CODE: |
| CITY: |
| Solicitation Number: |
| AI being offered: Off |
| 1: |
| What type AI: Off |
| 2: |
| Is the AI required for this product?: Off |
| Other: |
| 3: |
| Model: |
| 4: |
| license tier: |
| 5: |
| delivery: |
| Date2: |
| REPRESENTATIVE NAME: |
| BUSINESS TELEPHONE NUMBER: |
| ContactPhone: |
| Contact Name: |
| Contact Email: |
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