225827 RFR M04_rfr_application_form Rev1.doc

The Commonwealth of Massachusetts

Executive Office of Health and Human Services

Department of Public Health

250 Washington Street, Boston, MA 02108-4619

Template Rev 5

APPLICATION RESPONSE FORM, INSTRUCTIONS, AND CHECKLIST

For use with the M04/M78 RFR Template General Instructions:

1. See the RFR and COMMBUYS posting for complete procurement specifications.

2. All responses are to be submitted using the online submission tools available to Vendors registered in COMMBUYS. There is no charge to register in COMMBUYS. To Register go to www.COMMBUYS.com and click on the “Register” link on the front page.

Bidders are solely responsible to monitor COMMBUYS for Bid amendments, if any. Bidders may monitor the record by frequently checking the Amendment Section on the Summary screen for the BID in COMMBUYS.

3. All Bidders are advised to allow adequate time for submission by considering potential online submission impediments like Internet traffic, Internet connection speed, file size, and file volume. DPH is not responsible for delays encountered by Bidders or their agents, or for a Bidder’s local hardware failures, such as computers or related networks, associated with bid compilation or submission. Bids submitted via COMMBUYS are time stamped by the COMMBUYS system clock which is considered the official time of record.

Formatting Instructions:

This document was prepared using Microsoft Word’s forms feature. Complete the form on your computer using Microsoft Word.

1. Save this document file to your computer.

2. Enter your responses in the text box, moving between the text boxes using the tab key on your keyboard.

3. Responses to check boxes are made by clicking once on the check box. To remove the X from a check box, click on the check box again.

4. Text responses are limited to a maximum number of characters and the limits are noted in each question. Once the maximum character limit is reached, MS Word will not allow more than this limit. Please note that a space is counted as a character and using the enter key to begin a new line in a response is also counted as a character. It is not recommended that applicants insert graphics into the responses. Spell-check does not work in text boxes.

5. Those with visual impairments may use an electronic text reader by unlocking the Application Response Form.

APPLICATION RESPONSE COVER PAGE

Make this the first page of your proposal.

RFR TITLE: Emotional Health Programs for Massachusetts

Nursing Home Residents RFR # 225827

Organization Organization Name: [ ] Address:

City: [ ] State: [ ] Zip: [ ] Vendor Code: [ ] CEO (Chief Executive Officer) First Name: [ ] Last Name: [ ]

FEIN: [ ]

Contact Person First Name: [ ] Last Name: [ ] Title: [ ]

Telephone: ( ) - FAX: ( ) - E-Mail: [ ] Contact Person Address (if different):

City: [ ] State: [ ] Zip: [ ]

Location of Proposed Service Program Name: [ Program Address:

City: [ ] State: [ ] Zip: [ ]

QUESTIONS FOR RESPONSE

Enter your response in the text boxes using Microsoft Word. All questions must be answered for your application and response to be considered complete.

1. To receive a contract with state a vendor must be active in The Massachusetts Management Accounting and Reporting System (MMARS). MMARS is the official accounting system of the Commonwealth and once registered a vendor will be issued a Vendor Code number or a “VC” number. Only potential bidders who are new to the state system or who will need to update existing information in MMARS must complete and return the, W-9, EFT forms as well as the Contractor Authorized Signature Form found in the Vendor Activation Folder (VENDACT). Follow the instructions on the Vendor Activation Cover Page and indicate below which option was chosen to submit the documents. (Not scored)

Option 1 – Vendor Activation documents including Vendor Activation Cover Page mailed

Option 2 – Will complete W9 and EFT through DocuSign, Contract Authorized Signature Form and Vendor Activation Cover Page uploaded with application.

2. Bidders must complete the SDP Plan Form found in the Attachment section of this procurement and upload it with their bid response. In addition to proposing an SDP Commitment, each Bidder must propose one or more SDP Partner(s) to utilize in order to meet its SDP Commitment. Certified diverse Bidders may not list their own companies, or their subsidiaries or affiliates, as SDP Partners and may not meet their SDP Commitment by spending funds internally or with their own subsidiaries or affiliates. (25 Points)

SDP plan form is uploaded to COMMBUYS

3. a. Provide a brief abstract of the proposed program (text input limit 1,875 characters, approximately 300 words):

Enter text here; text limit 1,875 characters

b. Attach an organizational chart that shows the location of the proposed program within your agency.

c. Attach specific organizational chart indicating the structure of the project

d. Attach CV’s of key personnel Organization Chart uploaded to COMMBUYS.

Organizational Chart for Structure of Project uploaded to COMMBUYS.

CV’s of key personnel uploaded to COMMBUYS.

4. Describe how the proposed program will meet the requirements of the CMS CMP programs, specifically how they will improve quality of life and strengthen health outcomes for nursing home residents(text input limit 1,250 characters, approximately 200 words).

Enter text here: text limit 1,250 characters Attach a copy of your organization’s most recent mission statement to this response.

Most recent mission statement uploaded to COMMBUYS.

5. Briefly describe your experience in providing the type of program proposed in this RFR (text input limit 3,000 characters, approximately 500 words):

Enter text here; text limit 3,000 characters

6. If the proposal being submitted contains subcontracts, name the proposed subcontractors. Describe how the subcontracts will function, including descriptions of responsible parties and structures for operation and accountability. All subcontracts are subject to DPH approval. If you are proposing to use subcontractors, complete the Proposed Subcontractor List for non-direct services, found in the COMMBUYS Bid Attachment Section (text input limit 2,500 characters, approximately 400 words):

Enter text here; text limit 2,500 characters Proposed Subcontractor List for non-direct services uploaded to COMMBUYS.

7. Program Budget: Provide a line-item budget with justification narrative.

Program Budget and Budget Narrative is attached.

Provide a program budget justification narrative. Demonstrate how each budget item supports the overall program. (text input limit 6,000 characters, approximately one page):

Enter text here; text limit 6,000 characters

APPLICATION RESPONSE SUBMISSION PAGE

RFR TITLE: Emotional Health Programs for Massachusetts

Nursing Home Residents RFR # 225827

Organization

I affirm that I will comply with the requirements of this Request for Response and with the terms of this proposal.

Authorized Signatory:

First Name: [ ] Last Name: [ ] Title: [ ]

FORMTEXT

By clicking the check box, the submitter attests that s/he is an agent of the Bidder with authority to sign on the Bidder’s behalf and is agreeing all affirmations listed above.

CHECKLIST OF ATTACHMENTS TO THE APPLICATION RESPONSE FORM

All documents listed below must be submitted via COMMBUYS in order for your response to be considered complete. Files must be uploaded and follow the naming convention indicated in the chart.

Document Title

File Name

Assign when creating documents

Application Response Form

Company Name _ 225827 _App Resp Form

Organization Chart

Company Name _ 225827_Org Chart

Organizational Chart for Structure of Project Company Name _ 225827_Project Structure

CV’s of key project personnel Company Name _ 225827_(Last Name)_CV

Supplier Diversity Program Form for POS

Company Name _ 225827 _SDP Form for POS

Mission Statement

Company Name _ 225827 _Mission Statement

Proposed Subcontractor Identification List

Company Name _ 225827_ Sub-Contractor List

Program Budget

Company Name _ 225827 _Program Budget

Scope of Work with Budget crosswalk detailing cost breakdowns for individual deliverables/milestones with timetable attached.

Company Name _ 225827 _Scope of Work Scanned documents will be accepted. All scanned documents must be scanned in such a way that they can be read on a computer monitor and printed on 81/2” x 11” paper, unless otherwise specified. Zipped files will be accepted and must be in a .zip format when saved. Other zip file formats will not be accepted.

Addendums or uploads not specifically requested in this document, the RFR or on the COMMBUYS Bid Solicitation screen will not be reviewed.

APPLICATION INSTRUCTIONS

1. Save, read and review the completed Application Response Form. Check entries in the text boxes to assure that the input limits did not shorten your response. Proof read text; spell-check does not work in the text boxes.

2. Upload in COMMBUYS the Application Response Form with the attachments according to the application Checklist.

3. Confirm that “No Charge” is checked or a dollar amount entered in the Unit Cost field on the Item screen in COMMBUYS. The “No Charge” selection will not be construed by the Purchaser to mean an offer to provide service or products at no charge.

4. Submit your electronic quote in COMMBUYS. (Vendors must be registered in COMMBUYS to submit quotes)

RFR #______

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