2-HSS-26-057-AppC-Vendor Frms.xlsx
XLSX spreadsheet 35 KB Posted
- Solicitation number
- HSS-26-057
- Issued by
- Delaware
About this file
This is a vendor forms document supporting a Request for Proposal issued by the Delaware Department of Health and Social Services, Division of Public Health, for the administration and analysis of three youth health surveys: the Youth Risk Behavior Survey (YRBS), School Health Profiles survey, and Delaware Youth Tobacco Survey (YTS). The RFP will result in two separate contracts based on federal grant funding: one combining YRBS (conducted in odd-numbered years) and Profiles surveys (conducted in even-numbered years), and a second for the YTS survey (conducted in even-numbered years). The selected contractor will be responsible for data collection and analysis services in accordance with established CDC policies, guidelines, and protocols. The contract term commences on or around November 1, 2026, covering twelve months through October 31 of the following year, with subsequent contract years to follow similar timelines.
The vendor forms document provides the standardized application materials and forms required for submission by prospective contractors responding to this solicitation. These forms establish uniform requirements for vendor qualification, pricing submission, and other essential contractual information. The surveys are designed to collect data on Delaware youth risk behaviors to strengthen the state's capacity to address health inequities and understand disparities in health outcomes among the youth population. Selected contractors will provide datasets containing the required minimum number of responses to each questionnaire to both DHSS/DPH and the U.S. Centers for Disease Control and Prevention.
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Other files
| File | Type | Posted |
|---|---|---|
| 3-HSS-26-057-AppD-Templates-PSA, BAA and DTI TCs.docx | DOCX document | |
| 1-HSS-26-057 - Adm Anlys of YRBS Sch Hlth Profl YTS Surveys.docx | DOCX document |
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Attachment2Vendor Info Sheet
| Vendor Information Sheet | ||
| Company Name | ||
| DBA (if applicable) | ||
| Purchase Order Address | ||
| Website | ||
| Diverse Vendor Self-Identification | ||
| State Certified (select drop down of "Yes" or "No") | If yes, which State(s): | |
| Federal Certified (select drop down of "Yes" or "No") | ||
| Desginated Contacts | Primary | Secondary |
| Contact Name | ||
| Role/Title | ||
| Phone Number | ||
| Business Capability Statement | ||
| (Provide a short capability statement about your business and its capabilities and skills to advertise who you are and what you do.) |
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Attachment3Non-Collusion Stmt
| Non-Collusion Statement | |
| This is to certify that the undersigned Vendor has neither directly nor indirectly, entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free competitive bidding in connection with this solicitation, and further certifies that it is not a sub-contractor to another Vendor who also submitted a bid/proposal as a primary Vendor in response to this solicitation submitted this date to the State of Delaware, Office of Management and Budget, Government Support Services. | |
| It is agreed by the undersigned Vendor that the signed submission of this bid/proposal represents, subject to any express exceptions set forth on the Exception form, the Vendor’s acceptance of the terms and conditions of this solicitation including all specifications and special provisions. | |
| NOTE: Signature of the authorized representative MUST be of an individual who legally may enter his/her organization into a formal contract with the State of Delaware, Office of Management and Budget, Government Support Services. | |
| Company Name | |
| DBA (if applicable) | |
| Name of Authorized Representative | |
| Title | |
| Phone Number | |
| Email Address | |
| Company Address | |
| Phone Number | |
| Email Address | |
| Tax ID Number | |
| AFFIRMATION: Within the past five (5) years, has your firm, any affiliate, any predecessor company or entity, owner, Director, officer, partner or proprietor been the subject of a Federal, State, Local government suspension or debarment? | |
| Select "Yes" or "No" from the drop down menu | |
| If yes, explain |
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Attachment4Exceptions Form
| Exceptions Form | |||||
| Responding Vendors may elect to take minor exceptions to the terms and conditions of this solicitation. All exceptions must be submitted below. Exceptions found elsewhere in the solicitation response will not be considered. Government Support Services maintains sole discretion to reject any exceptions. | |||||
| Exceptions | |||||
| Paragraph & Page # of Document | Current Language stated in the document | Proposed Alternative language | Justification for proposed change | State of Delaware's response | Bidder's response |
If addition space is needed, please copy the format of this worksheet and attach as an additional file in your submission
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Attachment5Confidentiality Form
| Confidentiality Form |
| Responding vendor may elect to designate sections of their proposal as confidential, intellectual property, trade secrets, and other confidential business information. Vendor shall explain below how the redacted information is not “public record” as defined by 29 Del. C. § 10002. The State shall independently determine the validity of any vendor designation as set forth in this section. Any vendor submitting a bid/proposal herein expressly accepts the State’s absolute right and duty to independently assess the legal and factual validity of any information designated as confidential business information. |
| Confidential Information (select "Yes" or "No" on the dropdown) |
| Confidentiality and Proprietary Information |
If addition space is needed, please copy the format of this worksheet and attach as an additional file in your submission
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Attachment 6Business References
| Business References |
| List a minimum of three business references of similar size and scope. Please do not list any State Employee(s) as a business reference. If Subcontractors are identified, a minimum of three business references must also be provided for each subcontractor. |
| Reference One |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
| Reference Two |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
| Reference Three |
| Contact Name |
| Contact Title |
| Business Name |
| Address |
| Phone |
| Current Vendor? |
| Work Performed |
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Attachment7Subcontractor Form
| Subcontractor Form | |
| Are you proposing the use of any subcontractors in the fulfillment of the requirements as outlined in the solicitation? (Please select "Yes" or "No" in the drop down meniu) | |
| If yes, complete this form. | |
| Responding Vendor Information | |
| Company Name | |
| DBA (if applicable) | |
| Company Address | |
| Subcontractor Information | |
| Company Name | |
| DBA (if applicable) | |
| Company Address | |
| Diverse Vendor Self-Identification | |
| State Certified | If yes, which State(s): |
| Federal Certified | |
| Description of Work by Subcontractor |
| Once completed, this form must be signed by both vendors. | |
| Proposing Vendor | Subcontractor |
| Authorized Signature: | Authorized Signature: |
| Name: | Name: |
| Title: | Title: |
| Date: | Date: |
DropDowns
| YES |
| NO |
| YES - Vendor is providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. Ch. 100, Delaware Freedom of Information Act. |
| NO - Vendor is not providing any information they declare to be confidential or proprietary for the purpose of production under 29 Del. C. Ch. 100, Delaware Freedom of Information Act. |
| YES - Vendor is submitting exceptions for consideration. |
| NO - Vendor is not submitting any exceptions to the specifications, terms, or conditions found in this solicitation. |
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