25-10302_RFP_Attachments_(Fillable).pdf

California Department of Public Health

ATTACHMENT 1 – MANDATORY NON-BINDING LETTER OF INTENT

Purpose This is a non-binding Letter of Intent whose purpose is to assist CDPH in determining the staffing needs for the proposal evaluation process and to improve future procurements.

Information requested

CDPH is interested in knowing if your firm intends to submit a proposal or your reasons for not submitting a proposal. Completion of this form is Mandatory.

Action to take

Indicate your intention to submit a proposal by checking items 1 or 2 below. Follow the instructions below your selection.

1. My firm intends to submit a proposal.

A. Check box number 1 if the above statement reflects your intention.

B. Complete the bottom portion of this form and return it to CDPH as instructed in the

RFP section entitled, “Mandatory Non-Binding Letter of Intent”.

2. My firm does not intend to submit a proposal for this project.

A. Check box number 2 if the statement in item 2 reflects your intention.

B. Indicate the reason(s) for not submitting a proposal by checking each of the following statements that apply.

My firm lacks sufficient staff expertise or personnel resources to meet all RFP requirements.

My firm believes the qualification requirements are too restrictive.

Too much paperwork is required to prepare a proposal response. Other commitments and projects have a greater priority.

My firm did not learn about the contract opportunity soon enough.

My firm cannot meet the DVBE requirements - we do not wish to subcontract any work out. Too much effort and/or paperwork is required to meet California DVBE requirements.

Insufficient time was allowed for DVBE compliance.

Other reason: __________________________________________________________

Complete the bottom portion of this form and return it to CDPH as instructed in the RFP section entitled, “Mandatory Non-Binding Letter of Intent”. By indicating there is no intention to submit a proposal, CDPH may elect not to send your firm RFP clarification notices, RFP addenda, vendor questions and answers, or other procurement notices.

Name of Firm:

Printed Name/Title:

Signature Date:

ATTACHMENT 2 – PROPOSAL COVER PAGE

Name of Bidding Firm (Legal name as it will appear on the contract)

Mailing Address (Street address, P.O. Box, City, State, Zip Code)

Person authorized to act as the primary contact for matters regarding this proposal:

Printed Name (First, Last): Title:

Telephone number: Fax number: Email address

Person authorized to obligate this firm in matters regarding the resulting contract:

Telephone number: Fax number: Email address

(CORPORATIONS) Name/Title of person authorized by the Board of Directors to sign all proposal documents on behalf of the Board:

Signature of Vendor or Authorized Representative Date:

ATTACHMENT 3 – PROPOSER PREVIOUS EXPERIENCE SUMMARY

Attached alongside documents on the Cal eProcure Event Posting.

THE REST OF THIS PAGE IS INTENTIONALLY LEFT BLANK

ATTACHMENT 4 – CLIENT REFERENCES

Proposer Name:

List 3 clients served in the past 3 years to whom the Respondent provided similar size and scope; please list the most recent first.

REFERENCE 1

Name of Firm

Street address City State Zip Code

Contact Person Telephone number

Dates of service Value or cost of service Email Address

Brief description of service provided

REFERENCE 2

Name of Firm

Street address City State Zip Code

Contact Person Telephone number

Dates of service Value or cost of service Email Address

Brief description of service provided

REFERENCE 3

Name of Firm

Street address City State Zip Code

Contact Person Telephone number

Dates of service Value or cost of service Email Address

Brief description of service provided

If three references cannot be provided, explain why:

ATTACHMENT 5 – PROJECT PERSONNEL SUMMARY

ATTACHMENT 6 – COST PROPOSAL FORM

ATTACHMENT 7 – BUDGET DETAIL WORK SHEETS

ATTACHMENT 8 – SUBCONTRACTOR BUDGET DETAIL WORK SHEETS

ATTACHMENT 9 – REQUIRED ATTACHMENT / CERTIFICATION CHECKLIST

Complete this checklist to confirm the items in your proposal. Place a check mark or “X” next to each item that you are submitting to the State. For your bid to be responsive, all required attachments must be returned.

Confirmed by Proposer

Qualification Requirements. I certify that I meet the following qualification requirements:

Confirmed by CDPH

Yes No N/A (Corporations) My firm is in good standing and qualified to conduct business in California. [Check “N/A” if not a Corporation.]

Yes No N/A

Yes No N/A (Nonprofit Organizations) My firm is eligible to claim nonprofit status.

[Check “N/A” if not a nonprofit organization.]

Yes No N/A

Yes No

My firm has a past record of sound business integrity and a history of being responsive to past contractual obligations. My firm authorizes the State to confirm this claim.

Yes No

Yes No

My firm has certified via Attachment 9 that its bid response is not in violation of Public Contract Code Section 10365.5 and has, if applicable, identified previous State consultant services contracts entered into that were related in any manner to the services, goods, or supplies being acquired in this procurement.

Yes No

Confirmed by Proposer

Bid Content. I have completed and returned the following Attachments included in the Bid Package:

Confirmed by CDPH

Yes No Attachment 2, Proposal Cover Page Yes

No Yes No Attachment 3, Proposer Previous Experience Summary Yes

No Yes No Attachment 4, Client References Yes

No Yes No

N/A Attachment 5, Project Personnel Summary

Yes No N/A

Yes No Attachment 6, Cost Proposal form Yes

No Yes No Attachment 7, Budget Detail Work Sheets Yes

No Yes No Attachment 8, Subcontractor Budget Detail Work Sheets Yes

No Yes No Attachment 9, Required Attachment / Certification Checklist Yes

No Yes No

N/A Attachment 10, Business Information Sheet

Yes No N/A

Yes No

Attachment 11, Payee Data Record & Supplement (STD 204 & STD 205)

Yes No

Confirmed by Proposer

Bid Content. I have completed and returned the following Attachments included in the Bid Package:

Confirmed by CDPH

Yes No N/A Attachment 12, Bidder Declaration (GSPD-05-106)

Yes No N/A

Yes No Attachment 13, Commercially Useful Function (CUF) Certification Yes

No Yes No Attachment 14, Disabled Veteran Business Enterprise Declarations Yes

No Yes No Attachment 15, Target Area Contract Preference Act (TACPA) Yes

No Yes No Attachment 16, Contractor Certification Clauses (CCC 04/2017) Yes

No Yes No Attachment 17, Follow-On Consultant Contract Disclosure Yes

No Yes No Attachment 18, Contractor Confidentiality Statement Yes

No Yes No Attachment 19, Conflict of Interest Compliance Certification Form Yes

No Yes No Attachment 20, Darfur Contracting Act of 2008 Yes

No Yes No Attachment 21, California Civil Rights Laws Attachment Yes

No Yes No N/A Attachment 22, Iran Contracting Act Verification Form

Yes No N/A

Yes No N/A

(California Businesses) Copy of a current business license issued by

Yes No N/A

Yes No N/A

(Corporations) Either a copy of the Certificate of Status issued by California’s Office of the Secretary of State or a copy of the bidding firm’s active on-line status information downloaded from the California Business Portal website. Attach an explanation if the required documentation cannot be supplied. Check “N/A” if not a Corporation.

Yes No N/A

Yes No N/A

(Nonprofit Organizations) A copy of a current IRS determination letter Yes No

N/A Proposer Signature Date

(California Businesses) Copy of a current business license issued by the government jurisdiction in which the business is located, unless no license is required. Attach an explanation if a license copy cannot be supplied or there is reason to believe no license is required..

Check “N/A” if not a California business or no business license is required.

(Nonprofit Organizations) A copy of a current IRS determination letter indicating nonprofit or 501 (3) (c) tax exempt status. Check “N/A” if not a nonprofit organization.

ATTACHMENT 10 – BUSINESS INFORMATION SHEET

A signature affixed hereon and dated certifies compliance with all bid requirements. The signature below authorizes the State to verify the claims made on this form.

Name of Bidding Firm: CA Corp. No. (If applicable) Federal ID

Name of Principal (If not an

Title: Telephone Number Fax Number

Street Address / P.O. Box City State Zip Code

Type of Business Organization / Ownership (Check all that apply) Ownership

Sole Proprietor Partnership Joint venture Association

Corporation Nonprofit For Profit Private Public

Governmental City/County, California State Agency, Federal Agency, State (other than California)

Other:

Other Type of Entity Public or Municipal Corporation, School or

Water District, California State College, University of California, Joint Powers Agency

Auxiliary College Foundation Other:

California Certified Small Business Status N/A Microbusiness Small business NVSA Certified By DGS Certification No: Expiration Date:

If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:

Small Business Type (If applicable) N/A Services Non-Manufacturer Manufacturer

Contractor (Construction Type): Contractor’s License Type:

Veteran Status of Business Owner N/A (not a veteran or not certified by DGS) Disabled Veteran Certified by DGS Certification No. Expiration Date:

If certified, attach a copy of certification letter. If an application is pending, date submitted to DGS:

Disadvantaged Business Enterprise Status: N/A Approved by the Cal Trans, Office of Civil Rights.

Certification number issued by Cal Trans: Expiration Date:

Indicate possession of required licenses and/or certifications (if applicable): N/A (None required) Contractor’s State Licensing Board No. PUC License Number Required Licenses/Certifications (If

CAL-T-

Signature Date Signed

Printed/Typed Name Title

Public Records Information The above information is required for statistical reporting purposes. Completion of this form is mandatory. This information will be made public upon award of the contract and will be supplied to department contract staff, California Department of General Services, and possibly other public agencies. To access contract related records, contact the Contract Management Unit, 1616 Capitol Avenue, MS 1802, P.O. Box 997377, Sacramento, CA 95899-7377 or call 916-601-7241.

ATTACHMENT 11 – PAYEE DATA RECORD & SUPPLEMENT (STD 204 & STD 205)

All bidders must complete the Payee Data Record (STD 204 & STD 205) and include it with the bid response.

The Payee Data Record (STD 204) is available at the following website:

http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf.

The Payee Data Record Supplement (STD 205) is available at the following website:

https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std205.pdf.

If you do not have internet access, please contact the CCSU Analyst listed on this solicitation.

ATTACHMENT 12 – BIDDER DECLARATION FORM (GSPD-05-105)

All bidders must complete the Bidder Declaration Form (GSPD-05-105) and include it with the bid response.

The Bidder Declaration Form can be found at:

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd05-105.pdf.

If you do not have internet access, please contact the CCSU Analyst listed on this solicitation.

http://www.documents.dgs.ca.gov/dgs/fmc/pdf/std204.pdf https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std205.pdf https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd05-105.pdf

ATTACHMENT 13 – COMMERCIALLY USEFUL FUNCTION (CUF) CERTIFICATION

ATTACHMENT 14 – DISABLED VETERAN BUSINESS ENTERPRISE DECLARATIONS

Bidders who are disabled veteran (DV) owner(s) and DV manager(s) of a Disabled Veteran Business

Enterprise must complete Disabled Veteran Business Enterprise Declaration (STD 843) when a DVBE contractor or subcontractor will provide materials, supplies, services, or equipment and include it with the bid response.

The STD 843 Disabled Veteran Business Enterprise Declarations form can be found at:

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/pd_843.pdf.

If you do not have internet access, please contact the CCSU Analyst listed on this solicitation.

ATTACHMENT 15 – TARGET AREA CONTRACT PREFERENCE ACT (TACPA)

The Target Area Contract Preference Act economic stimulus preference program was established to stimulate business investment in distressed areas of the state and create job opportunities for

Californians for improving the economic vitality of their communities.

If applying for this preference, bidders must submit the preference request forms listed in the

Attachments section of this document. Denial of TACPA preference requests is not a basis for rejection of the bid.

For more information: https://www.dgs.ca.gov/PD/Services/Page-Content/Procurement-Division-

Services-List-Folder/Request-a-Target-Area-Contract-Preference?search=tacpa

The STD 830 Target Area Contract Preference Act Preference Request for Goods and Services

Solicitations form can be found at: https://www.documents.dgs.ca.gov/dgs/fmc/pdf/Std830.pdf.

The DGS/PD 525 Manufacturer’s Summary of Contract Activities and Labor Hours form can be found at: https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd0525.pdf.

The DGS/PD 526 Bidder’s Summary of Contract Activities and Labor Hours form can be found at:

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd0526.pdf.

https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/pd_843.pdf https://www.dgs.ca.gov/PD/Services/Page-Content/Procurement-Division-Services-List-Folder/Request-a-Target-Area-Contract-Preference?search=tacpa https://www.dgs.ca.gov/PD/Services/Page-Content/Procurement-Division-Services-List-Folder/Request-a-Target-Area-Contract-Preference?search=tacpa https://www.documents.dgs.ca.gov/dgs/fmc/pdf/Std830.pdf https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd0525.pdf https://www.documents.dgs.ca.gov/dgs/fmc/gs/pd/gspd0526.pdf

ATTACHMENT 16 – CONTRACTOR CERTIFICATION CLAUSES (CCC 04/2017)

All bidders must complete the Contractor Certification Clauses form (CCC 04/2017) and include it with the bid response.

The Contractor Certification Clauses Form (CCC 04/2017) is available at the following website:

https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-

Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language https://www.dgs.ca.gov/OLS/Resources/Page-Content/Office-of-Legal-Services-Resources-List-Folder/Standard-Contract-Language

ATTACHMENT 17 – FOLLOW-ON CONSULTANT CONTRACT DISCLOSURE

Must be completed by Proposer and each subcontractor

Background Information:

1. PCC Section 10365.5 generally prohibits a person, firm, or subsidiary thereof that has been awarded a consulting services contract from submitting a bid for and/or being awarded a contract for, the provision of services, procurement of goods or supplies, or any other related action that is required, suggested, or otherwise deemed appropriate in the end product of a consulting services contract.

2. PCC Section 10365.5 does not apply to any person, firm, or subsidiary thereof that is awarded a subcontract of a consulting services contract that totals no more than 10 percent of the total monetary value of the consulting services contract.

3. Consultants/employees of a firm that provides consulting advice under an original consulting contract are not prohibited from providing services as employees of another firm on a follow-on contract, unless the persons are named contracting parties or named parties in a subcontract of the original contract.

4. PCC Section 10365.5 does not distinguish between intentional, negligent, and/or inadvertent violations. A violation could result in disqualification from bidding, a void contract, and/or imposition of criminal penalties.

Disclosure [Mark one (1) box]:

I hereby certify that neither my firm nor any subcontractor that my firm intends to use under the contract resulting from this procurement, is currently providing consulting services to the state under a state contract (or as a subcontractor providing more than 10 percent of dollar value of a consulting service contract with the state) or has provided such services within five (5) years prior to the release of this RFO that are related in any manner to the services, goods, or supplies being acquired pursuant to this RFO. [Sign below.] This option is likely to apply to bidding firms that do not currently and/or never have provided consultant services to the State.

Attached is a disclosure of current and/or prior consulting services provided by my firm or a proposed subcontractor to the state under a state contract within five (5) years prior to the release of this RFO that may be related in some manner to the services, goods, or supplies being acquired pursuant to this RFO. [Sign below and attach to this document a detailed disclosure.]

Name of Responding Firm

Signature Date Signed

Printed/Typed Name Title

ATTACHMENT 18 – CONTRACTOR CONFIDENTIALITY STATEMENT

As an authorized representative and/or corporate officer of the company named below, I warrant my company and its employees will not disclose any documents, diagrams, information and information storage media made available to us by the State and marked confidential for the purpose of responding to this RFP or in conjunction with any contract arising there from. I warrant that only those employees who are authorized and required to use such materials will have access to them.

I further warrant that all materials provided by the State will be returned promptly after use and that all copies or derivations of the materials will be physically and/or electronically destroyed. I will include with the returned materials, a letter attesting to the complete return of materials, and documenting the destruction of copies and derivations. Failure to so comply will subject this company to liability, both criminal and civil, including all damages to the State and third parties.

I authorize the State to inspect and verify the above.

I warrant that if my company is awarded the Contract, it will not enter into any agreements or discussions with a third party concerning such materials prior to receiving written confirmation from the State that such third party has an agreement with the State similar in nature to this one.

Signature of Representative Date (mm/dd/yyyy)

Typed Name of Representative Typed Name of Company

ATTACHMENT 19 – CONFLICT OF INTEREST CERTIFICATION

A. This certification shall be completed by the vendor and any proposed subcontractors and submitted with the Cover Letter and other attachments required in Stage 1- (Required

Attachment / Certification Checklist review) of the proposal.

B. The California Department of Public Health (CDPH) intends to avoid conflicts of interest or the appearance of conflicts of interest on the part of the Contractor, subcontractors, and employees, officers, and directors of the Contractor or subcontractors. Thus, CDPH reserves the right to determine, at its sole discretion, whether any information received from any source indicates the existence of a conflict of interest. For purposes of this certification and disclosing conflicts of interest, “vendor/Contractor” includes holding companies, parent companies, and affiliate companies. Because of the complexities involved in defining potential conflicts of interest with the mission of CDPH, CDPH reserves the right to request further information if needed.

C. If CDPH is aware of a known or suspected conflict of interest, the vendor or Contractor will be given an opportunity to submit additional information or to resolve the conflict. A vendor or

Contractor with a suspected conflict of interest will have five (5) working days from the date of notification of the conflict by CDPH to provide complete information regarding the suspected conflict. If a conflict of interest is determined to exist by CDPH and cannot be resolved to the satisfaction of CDPH, before or after the award of the contract, the conflict will be grounds for rejection of the proposal and/or termination of the contract.

D. This Certificate shall bear the original signature of an official or employee of the vendor who is authorized to bind the vendor.

E. This Certificate will be incorporated into the contract, if any, awarded from this Solicitation for

Proposals. The Contractor shall obtain a completed Certificate from any proposed subcontractor and submit it to CDPH prior to commencement of work by the subcontractor.

ATTACHMENT 19 – CONFLICT OF INTEREST CERTIFICATION (Continued)

F. During the entire term of the contract the Contractor and each subcontractor, via the

Contractor, shall notify CDPH, MS 1802, 1616 Capitol Avenue, Sacramento, CA 95814 within ten (10) working days of any change to the information provided on this Certificate.

G. If the vendor has a suspected or potential conflict of interest, the vendor shall attach to this form a description of the relationship, a plan for ensuring that such a relationship will not adversely affect CDPH, and procedures to guard against the existence of an actual conflict of interest.

The undersigned hereby affirms that (check one):

☐ The statements above have been read, and the undersigned agency has determined that no conflict of interest exists.

☐ A suspected or potential conflict of interest does exist, and additional information is attached along with a plan to address the possible conflict of interest.

Signed: _____________________ Title: ___________________________________

Date: __________________________

Name of Authorized Representative __________________________________

Agency _________________________________

ATTACHMENT 20 – DARFUR CONTRACTING ACT

All bidders must complete the Darfur Contracting Act and include it with the bid response.

The Darfur Contracting Act Attachment is available at the following website:

http://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/PD_1.pdf.

ATTACHMENT 21 – CALIFORNIA CIVIL RIGHTS LAWS CERTIFICATION

All Proposers must complete and sign the California Civil Rights Laws Certification and include it with proposal.

The California Civil Rights Laws Certification is available at the following website:

http://www.documents.dgs.ca.gov/dgs/FMC/DGS/OLS004.pdf

If you are unable to access this form, please contact the Department Contact on the cover page.

ATTACHMENT 22 – IRAN CONTRACTING ACT VERIFICATION FORM

All Proposers must complete and sign the Iran Contracting Act Verification Form and include it with proposal.

The Iran Contracting Act Verification Form is available at the following website:

https://www.dgs.ca.gov/-

/media/Divisions/PD/PTCS/OPPL/SCM/Iran_Contracting_Act_Verification_Form.pdf

If you are unable to access this form, please contact the Department Contact on the cover page.

THE REST OF THIS PAGE IS INTENTIONALLY LEFT BLANK

http://www.documents.dgs.ca.gov/dgs/FMC/GS/PD/PD_1.pdf https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std1000.pdf https://www.documents.dgs.ca.gov/dgs/fmc/pdf/std1000.pdf